Provider Demographics
NPI:1659392611
Name:LEWIS FAMILY DRUG, LLC
Entity Type:Organization
Organization Name:LEWIS FAMILY DRUG, LLC
Other - Org Name:LEWIS FAMILY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF CORP SVCS
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-367-2824
Mailing Address - Street 1:2701 S MINNESOTA AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4744
Mailing Address - Country:US
Mailing Address - Phone:605-367-2800
Mailing Address - Fax:
Practice Address - Street 1:7220 W 41ST ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6038
Practice Address - Country:US
Practice Address - Phone:605-367-2010
Practice Address - Fax:605-274-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1001877333600000X
3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8504280Medicaid
4353796OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1276580017Medicare ID - Type Unspecified