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General NPI Number Information
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NPI Number | 1326151432
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Entity Type | Organization
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Legal Business Name | EAST LAKE PHARMACY INC
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1896 E LAKE RD
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City | ERIE
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State | PA
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Zip | 16511-1072
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Country | US
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Telephone | 814-456-4108
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Fax | 814-456-4417
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Provider Business Mailing Address
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Address Line | 1896 E LAKE RD
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City | ERIE
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State | PA
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Zip | 16511-1072
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Country | US
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Telephone | 814-456-4108
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Fax | 814-456-4417
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Authorized Official
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Title or Position | OWNER
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Name | RICHARD J KOSOBUCKI
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Credential | RPH
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Telephone | 814-456-4108
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PP481227
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License Number State | PA
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