Provider Demographics
NPI:1104257666
Name:LAKEWOOD PHARMACY INC
Entity type:Organization
Organization Name:LAKEWOOD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-507-7492
Mailing Address - Street 1:1902 96TH ST S
Mailing Address - Street 2:STE A
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-2808
Mailing Address - Country:US
Mailing Address - Phone:253-302-4178
Mailing Address - Fax:253-503-0858
Practice Address - Street 1:1902 96TH ST S STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-2808
Practice Address - Country:US
Practice Address - Phone:253-302-4178
Practice Address - Fax:253-503-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
WAPHAR.CF.603539053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034106Medicaid
2143288OtherPK