Healthcare Provider Details

I. General information

NPI: 1356288450
Provider Name (Legal Business Name): LAKE BUENA VISTA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13401 BLUE HERON BEACH DR STE 101
ORLANDO FL
32821-6375
US

IV. Provider business mailing address

13401 BLUE HERON BEACH DR STE 101
ORLANDO FL
32821-6375
US

V. Phone/Fax

Practice location:
  • Phone: 407-951-4590
  • Fax:
Mailing address:
  • Phone: 407-951-4590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MILLAD KAMAL LABIB AYYAD
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 407-951-4590