Provider Demographics
NPI:1063527018
Name:LAKESIDE PHARMACY
Entity type:Organization
Organization Name:LAKESIDE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-245-7699
Mailing Address - Street 1:31681 RIVERSIDE DR
Mailing Address - Street 2:STE D
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31681 RIVERSIDE DR
Practice Address - Street 2:STE D
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7815
Practice Address - Country:US
Practice Address - Phone:951-245-7699
Practice Address - Fax:951-245-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY473863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5623283OtherOTHER ID NUMBER-COMMERCIAL NUMBER