Provider Demographics
NPI:1124452164
Name:LAKE, MICHAEL SUNDANCE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SUNDANCE
Last Name:LAKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SUMMER ST
Mailing Address - Street 2:APT 1
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-2218
Mailing Address - Country:US
Mailing Address - Phone:716-803-5564
Mailing Address - Fax:
Practice Address - Street 1:2887 HARLEM RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-3038
Practice Address - Country:US
Practice Address - Phone:716-892-8115
Practice Address - Fax:716-892-6027
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist