Provider Demographics
NPI:1154325199
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:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBOTKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-632-1830
Mailing Address - Street 1:516 MONUMENT SQ
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-1033
Mailing Address - Country:US
Mailing Address - Phone:262-632-0520
Mailing Address - Fax:262-632-6777
Practice Address - Street 1:516 MONUMENT SQ
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1033
Practice Address - Country:US
Practice Address - Phone:262-632-0520
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:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
WI7185-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2114710OtherPK
WI33069400Medicaid
2114710OtherPK