MEDICARE: LAKE EXPRESS PHARMACY INC

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	3336C0003X	Community/Retail Pharmacy

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

General Provider Information

NPI Number	:	1295351203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE EXPRESS PHARMACY INC

Provider Business Mailing Address
First Line	:	6308 GREBE CT
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-9314
Country	:	US
Telephone Number	:	561-523-4161
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 DR MLK BLVD E STE B
Second Line	:
City	:	BELLE GLADE
State	:	FL
Zip	:	33430-4044
Country	:	US
Telephone Number	:	561-523-4161
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MUHAMMAD ILYAS
Credential	:
Telephone Number	:	561-523-4161

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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Directions to “LAKE EXPRESS PHARMACY INC ” Practice Location

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