Provider Demographics
NPI:1457950735
Name:DEROSIER, LYNN MARIE
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:DEROSIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7295 GLORY RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-7308
Mailing Address - Country:US
Mailing Address - Phone:218-829-5510
Mailing Address - Fax:218-825-9141
Practice Address - Street 1:7295 GLORY RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-7308
Practice Address - Country:US
Practice Address - Phone:218-829-5510
Practice Address - Fax:218-825-9141
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist