MEDICARE: NORTHLAKE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PH30206	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2160865	OTHER		PK

General Provider Information

NPI Number	:	1053762260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAKE PHARMACY LLC

Provider Business Mailing Address
First Line	:	9091 N MILITARY TRL STE 17
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-5983
Country	:	US
Telephone Number	:	561-619-9900
Fax Number	:	561-619-9902

Provider Business Practice Location Address
First Line	:	9091 N MILITARY TRL STE 17
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-5983
Country	:	US
Telephone Number	:	561-619-9900
Fax Number	:	561-619-9902

Authorized Official
Title or Position	:	OWNER/PHARMACIST/AO
Name	:	SALIM SOUFAN
Credential	:	RPH
Telephone Number	:	561-562-2610

Provider Enumeration Date	:	06/29/2016
Last Update Date	:	03/14/2017

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