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General NPI Number Information
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NPI Number | 1467865337
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Entity Type | Organization
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Legal Business Name | GREAT LAKES PHARMACY
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Dates
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Enumeration Date | 06/08/2014
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Last Update Date | 05/17/2020
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Provider Practice Location Address
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Address Line | 9500 MENTOR AVE SUITE # 110
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City | MENTOR
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State | OH
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Zip | 44060-8713
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Country | US
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Telephone | 440-352-2500
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Fax | 440-352-2554
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Provider Business Mailing Address
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Address Line | 9500 MENTOR AVE SUITE # 110
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City | MENTOR
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State | OH
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Zip | 44060-8713
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Country | US
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Telephone | 440-352-2500
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Fax | 440-352-2554
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Authorized Official
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Title or Position | PHARMACY MANAGER/OWNER
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Name | MRS. KELLY ANNE MALKAMAKI
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Credential | RPH
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Telephone | 440-352-2500
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336M0002X
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Taxonomy Name | Mail Order Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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