Healthcare Provider Details

I. General information

NPI: 1225071566
Provider Name (Legal Business Name): LAKESIDE MEMORIAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 WEST AVE
BROCKPORT NY
14420-1229
US

IV. Provider business mailing address

156 WEST AVE
BROCKPORT NY
14420-1229
US

V. Phone/Fax

Practice location:
  • Phone: 585-395-6043
  • Fax: 585-395-6022
Mailing address:
  • Phone: 585-395-6043
  • Fax: 585-395-6022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number012799
License Number StateNY

VIII. Authorized Official

Name: CHRISTOPHER DAILEY
Title or Position: DIRECTOR FO PHARMACY
Credential:
Phone: 585-395-6043