Healthcare Provider Details

I. General information

NPI: 1295532026
Provider Name (Legal Business Name): THE LAKES ON 41 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FLAGSHIP DR
LUTZ FL
33549-5409
US

IV. Provider business mailing address

103 FLAGSHIP DR
LUTZ FL
33549-5409
US

V. Phone/Fax

Practice location:
  • Phone: 813-776-1277
  • Fax: 813-776-1551
Mailing address:
  • Phone: 813-776-1277
  • Fax: 813-776-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SANDRA GHOBRIAL
Title or Position: PHARMACY MANAGER
Credential:
Phone: 714-234-6610