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General NPI Number Information
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NPI Number | 1831608108
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Entity Type | Organization
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Legal Business Name | LAKE ODESSA PHARMACY
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Dates
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Enumeration Date | 09/29/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 802 4TH AVE
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City | LAKE ODESSA
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State | MI
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Zip | 48849-1002
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Country | US
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Telephone | 877-855-9777
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Fax | 877-855-8222
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Provider Business Mailing Address
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Address Line | 802 4TH AVE
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City | LAKE ODESSA
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State | MI
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Zip | 48849-1002
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Country | US
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Telephone | 877-855-9777
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Fax | 877-855-8222
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Authorized Official
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Title or Position | OWNER/PHARMACIST
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Name | ANDREA CUSACK
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Credential |
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Telephone | 877-855-9777
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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 | 5301011266
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License Number State | MI
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