Provider Demographics
NPI:1982980975
Name:MOLLIEN, LORELLE
Entity Type:Individual
Prefix:
First Name:LORELLE
Middle Name:
Last Name:MOLLIEN
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 1:3345 SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4394
Mailing Address - Country:US
Mailing Address - Phone:612-722-4249
Mailing Address - Fax:612-722-5713
Practice Address - Street 1:4547 HIAWATHA AVE
Practice Address - Street 2:C/O WALGREENS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3926
Practice Address - Country:US
Practice Address - Phone:612-722-4249
Practice Address - Fax:612-722-5713
Is Sole Proprietor?:No
Enumeration Date:2011-10-23
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist