Provider Demographics
NPI:1912146507
Name:LAKELAND CITY PHARMACY INC
Entity type:Organization
Organization Name:LAKELAND CITY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BANJOKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-257-0225
Mailing Address - Street 1:PO BOX 17175
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-7175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 E BLUE HERON BLVD
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-4543
Practice Address - Country:US
Practice Address - Phone:561-818-2233
Practice Address - Fax:855-225-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X
FLPH238203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118838OtherPK
FL104357200Medicaid