Provider Demographics
NPI:1972592889
Name:LAKE PHARMACY INC
Entity type:Organization
Organization Name:LAKE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPA
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:STORY
Authorized Official - Suffix:
Authorized Official - Credentials:RPA
Authorized Official - Phone:561-996-0200
Mailing Address - Street 1:PO BOX 977
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-0977
Mailing Address - Country:US
Mailing Address - Phone:561-996-0200
Mailing Address - Fax:561-996-0201
Practice Address - Street 1:25 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-4044
Practice Address - Country:US
Practice Address - Phone:561-996-0200
Practice Address - Fax:561-996-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH65513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033884OtherOTHER ID NUMBER
FL105213600Medicaid
DQ779AMedicare PIN