Provider Demographics
NPI:1932140837
Name:LAKEWOOD HEALTH SYSTEM
Entity Type:Organization
Organization Name:LAKEWOOD HEALTH SYSTEM
Other - Org Name:LAKEWOOD HEALTH SYSTEMS HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH PHARMD
Authorized Official - Phone:218-894-8454
Mailing Address - Street 1:49725 COUNTY ROAD 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479
Mailing Address - Country:US
Mailing Address - Phone:218-894-8454
Mailing Address - Fax:218-894-8451
Practice Address - Street 1:49725 COUNTY ROAD 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479
Practice Address - Country:US
Practice Address - Phone:218-894-8454
Practice Address - Fax:218-894-8451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336L0003X
MN2007483336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045707OtherPK
MN114247000Medicaid