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General NPI Number Information
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NPI Number | 1386174894
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Entity Type | Organization
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Legal Business Name | LAKE FOREST PHARMACY
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Dates
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Enumeration Date | 06/16/2017
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Last Update Date | 12/08/2019
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Provider Practice Location Address
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Address Line | 950 CORPORATE PKWY STE 104
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City | WENTZVILLE
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State | MO
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Zip | 63385-4851
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Country | US
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Telephone | 636-856-9555
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Fax | 866-548-7855
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Provider Business Mailing Address
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Address Line | 950 CORPORATE PKWY STE 104
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City | WENTZVILLE
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State | MO
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Zip | 63385-4851
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Country | US
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Telephone | 636-856-9555
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Fax | 866-548-7855
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Authorized Official
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Title or Position | OWNER
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Name | THOMAS WEGRZYN
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Credential |
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Telephone | 636-856-9555
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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 | 2017018401
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License Number State | MO
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