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General NPI Number Information
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NPI Number | 1023374063
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Entity Type | Organization
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Legal Business Name | EAGLE LAKE PHARMACY INC
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Dates
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Enumeration Date | 04/04/2012
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Last Update Date | 11/23/2016
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Provider Practice Location Address
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Address Line | 5245 A U S HWY 98 N SUITE A
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City | LAKELAND
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State | FL
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Zip | 33809
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Country | US
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Telephone | 863-937-7992
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Fax | 863-937-7994
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Provider Business Mailing Address
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Address Line | 5245 A U S HWY 98 N SUITE A
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City | LAKELAND
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State | FL
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Zip | 33809
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Country | US
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Telephone | 863-937-7992
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Fax | 863-937-7994
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Authorized Official
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Title or Position | OWNER
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Name | POLYCARP AGBARA
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Credential |
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Telephone | 863-738-8002
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH25608
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License Number State | FL
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