Provider Demographics
NPI:1306982913
Name:SUN AND LAKE PHARMACY SERVICES, INC
Entity type:Organization
Organization Name:SUN AND LAKE PHARMACY SERVICES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KWAME
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:863-688-5427
Mailing Address - Street 1:1231 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1231 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4673
Practice Address - Country:US
Practice Address - Phone:863-688-5427
Practice Address - Fax:863-688-5462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBP121476333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013767OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL030900100Medicaid
FL030900100Medicaid
FL030900100Medicaid