MEDICARE: LAKE TOWN 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	PH28934	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2154679	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093186546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE TOWN PHARMACY LLC

Provider Business Mailing Address
First Line	:	2020 CR N 470 UNIT B
Second Line	:
City	:	LAKE PANASOFFKEE
State	:	FL
Zip	:	33538
Country	:	US
Telephone Number	:	352-444-2055
Fax Number	:	352-569-4768

Provider Business Practice Location Address
First Line	:	2020 CR N 470 UNIT B
Second Line	:
City	:	LAKE PANASOFFKEE
State	:	FL
Zip	:	33538
Country	:	US
Telephone Number	:	352-444-2055
Fax Number	:	352-569-4768

Authorized Official
Title or Position	:	OWNER, AO, PHCY MANAGER, PIC
Name	:	RAJASEKARAN MANI
Credential	:
Telephone Number	:	239-246-0796

Provider Enumeration Date	:	10/09/2015
Last Update Date	:	09/24/2021

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Directions to “LAKE TOWN PHARMACY LLC ” Practice Location

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