Healthcare Provider Details

I. General information

NPI: 1568491413
Provider Name (Legal Business Name): LAKESHORE APOTHACARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WASHINGTON ST
TWO RIVERS WI
54241-3045
US

IV. Provider business mailing address

1500 WASHINGTON ST
TWO RIVERS WI
54241-3045
US

V. Phone/Fax

Practice location:
  • Phone: 920-794-1225
  • Fax: 920-794-7091
Mailing address:
  • Phone: 920-794-1225
  • Fax: 920-794-7091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7778
License Number StateWI

VIII. Authorized Official

Name: MR. BRIAN C JENSEN
Title or Position: OWNER/PRESIDENT
Credential: R. PH.
Phone: 920-794-1225