Provider Demographics
NPI:1528245883
Name:LAKE PARK PHARMACY, LLC
Entity type:Organization
Organization Name:LAKE PARK PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DORMINEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-559-9398
Mailing Address - Street 1:1016 LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-3013
Mailing Address - Country:US
Mailing Address - Phone:229-559-9394
Mailing Address - Fax:229-559-9408
Practice Address - Street 1:1016 LAKES BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636-3013
Practice Address - Country:US
Practice Address - Phone:229-559-9394
Practice Address - Fax:229-559-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008870332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5929630001Medicare NSC