Provider Demographics
NPI:1023107646
Name:LEWIS FAMILY DRUG L L C
Entity type:Organization
Organization Name:LEWIS FAMILY DRUG L L C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-367-2800
Mailing Address - Street 1:2701 S MINNESOTA AVE STE 1
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-4746
Mailing Address - Country:US
Mailing Address - Phone:605-367-2850
Mailing Address - Fax:605-367-2876
Practice Address - Street 1:202 S KNISS AVE
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156-1775
Practice Address - Country:US
Practice Address - Phone:507-283-9549
Practice Address - Fax:507-283-9540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
MN2616023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2047913OtherPK
MN534715700Medicaid
MN730000023OtherIMMUNIZATION - LEGACY
MN534715700Medicaid