Healthcare Provider Details

I. General information

NPI: 1508964537
Provider Name (Legal Business Name): LAKE PARK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 LAKES BLVD
LAKE PARK GA
31636-6607
US

IV. Provider business mailing address

453 LAKES BLVD
LAKE PARK GA
31636-6607
US

V. Phone/Fax

Practice location:
  • Phone: 229-559-9394
  • Fax: 229-559-9408
Mailing address:
  • Phone: 229-559-9394
  • Fax: 229-559-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE008870
License Number StateGA

VIII. Authorized Official

Name: HUGH CHANCY
Title or Position: OWNER
Credential: RPH
Phone: 229-794-3525