Provider Demographics
NPI:1063416097
Name:LAKEVIEW PHARMACY OF RACINE INC
Entity type:Organization
Organization Name:LAKEVIEW PHARMACY OF RACINE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:CIARAMITA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-632-8215
Mailing Address - Street 1:517 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1050
Mailing Address - Country:US
Mailing Address - Phone:262-632-8215
Mailing Address - Fax:262-632-6777
Practice Address - Street 1:517 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1050
Practice Address - Country:US
Practice Address - Phone:262-632-8215
Practice Address - Fax:262-632-6777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI7186-423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115320OtherPK
WI100032237Medicaid
WI33069400Medicaid
5121493OtherOTHER ID NUMBER-COMMERCIAL NUMBER