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General NPI Number Information
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NPI Number | 1407199169
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Entity Type | Organization
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Legal Business Name | LAKE ELLA PHARMACY
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Dates
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Enumeration Date | 04/01/2013
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Last Update Date | 12/27/2016
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Provider Practice Location Address
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Address Line | 2525 S MONROE ST STE 6
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City | TALLAHASSEE
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State | FL
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Zip | 32301-6353
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Country | US
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Telephone | 850-727-8736
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Fax | 850-727-8736
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Provider Business Mailing Address
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Address Line | 4313 MAYLOR LN
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City | TALLAHASSEE
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State | FL
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Zip | 32308-5773
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Country | US
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Telephone | 850-824-4660
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Fax | 850-727-8736
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Authorized Official
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Title or Position | OWNER / PIC
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Name | SAMUEL MENSAH-MAMFO
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Credential |
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Telephone | 850-284-4660
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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 | PH26779
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License Number State | FL
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