Provider Demographics
NPI:1447497953
Name:LAKE CEDAR PHARMACY
Entity type:Organization
Organization Name:LAKE CEDAR PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SAIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-987-2002
Mailing Address - Street 1:526 121ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-3380
Mailing Address - Country:US
Mailing Address - Phone:763-222-4199
Mailing Address - Fax:
Practice Address - Street 1:2423 E FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1026
Practice Address - Country:US
Practice Address - Phone:612-353-5532
Practice Address - Fax:612-353-5537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-21
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2632763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118628OtherPK
MN6707960001Medicare NSC