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	3336L0003X	Long Term Care Pharmacy

General Provider Information

NPI Number	:	1992468755
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	:	MANAGER
Name	:	PAUL O CONNOR
Credential	:
Telephone Number	:	561-531-1574

Provider Enumeration Date	:	10/19/2021
Last Update Date	:	10/19/2021

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