Healthcare Provider Details

I. General information

NPI: 1851320931
Provider Name (Legal Business Name): LAKESHORE PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 W LAKESHORE DR
BURNSIDE KY
42519-9424
US

IV. Provider business mailing address

51 W LAKESHORE DR
BURNSIDE KY
42519-9424
US

V. Phone/Fax

Practice location:
  • Phone: 606-561-7104
  • Fax: 606-561-9205
Mailing address:
  • Phone: 606-561-7104
  • Fax: 606-561-9205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP06673
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberP06673
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP06673
License Number StateKY

VIII. Authorized Official

Name: DR. PATTY GREGORY GUINN
Title or Position: PRESIDENT
Credential: PHARM.D.
Phone: 606-561-7104