Healthcare Provider Details

I. General information

NPI: 1093078768
Provider Name (Legal Business Name): LAKE SIDE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10005 AL HIGHWAY 9 N
CEDAR BLUFF AL
35959-2231
US

IV. Provider business mailing address

10005 AL HIGHWAY 9 N
CEDAR BLUFF AL
35959-2231
US

V. Phone/Fax

Practice location:
  • Phone: 844-236-5360
  • Fax: 866-609-4582
Mailing address:
  • Phone: 844-236-5360
  • Fax: 866-609-4582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number113926
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier113926
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerALABAMA PHARMACY LICENSE NUMBER

VIII. Authorized Official

Name: DR. STEPHEN WILSON
Title or Position: PHARMACIST IN CHARGE
Credential: PHARM.D.
Phone: 844-236-5360