Provider Demographics
NPI:1215477419
Name:BEAR LAKE PHARMACY, LLC
Entity type:Organization
Organization Name:BEAR LAKE PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SEIFERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-848-4442
Mailing Address - Street 1:3840 E SEMORAN BLVD
Mailing Address - Street 2:SUITE 1048
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-6197
Mailing Address - Country:US
Mailing Address - Phone:407-848-4442
Mailing Address - Fax:321-444-6731
Practice Address - Street 1:3840 E SEMORAN BLVD
Practice Address - Street 2:SUITE 1048
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-6197
Practice Address - Country:US
Practice Address - Phone:407-848-4442
Practice Address - Fax:321-444-6731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1516903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy