Provider Demographics
NPI:1386998623
Name:LBG HOLDINGS LLC
Entity type:Organization
Organization Name:LBG HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-929-2552
Mailing Address - Street 1:PO BOX 621255
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32762-1255
Mailing Address - Country:US
Mailing Address - Phone:352-315-1200
Mailing Address - Fax:352-315-1201
Practice Address - Street 1:2864 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4631
Practice Address - Country:US
Practice Address - Phone:352-315-1200
Practice Address - Fax:352-315-1201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X, 3336M0002X
FLPH301153336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacyGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008795700Medicaid
2144404OtherPK