Healthcare Provider Details

I. General information

NPI: 1689736746
Provider Name (Legal Business Name): LIVONIA LAKEVILLE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5975 BIG TREE RD
LAKEVILLE NY
14480-0414
US

IV. Provider business mailing address

PO BOX 414
LAKEVILLE NY
14480-0414
US

V. Phone/Fax

Practice location:
  • Phone: 585-346-5615
  • Fax: 585-346-2212
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number024333
License Number StateNY

VIII. Authorized Official

Name: JENNIFER BURKE
Title or Position: VICE PRESIDENT
Credential:
Phone: 585-346-5615