Provider Demographics
NPI:1710012646
Name:LAKE ELMO PHARMACY
Entity Type:Organization
Organization Name:LAKE ELMO PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:651-773-0889
Mailing Address - Street 1:11240 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9640
Mailing Address - Country:US
Mailing Address - Phone:651-773-0889
Mailing Address - Fax:
Practice Address - Street 1:11240 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9640
Practice Address - Country:US
Practice Address - Phone:651-773-0889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2611044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2419275OtherNABP NUMBER