=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487805701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE ESCAPE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2008
-----------------------------------------------------
Last Update Date | 10/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 378 W HARDEN ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-7516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-222-9811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 378 W HARDEN ST
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-7516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-222-9811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL D SMITH
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 336-222-9811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5919
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------