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General NPI Number Information
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NPI Number | 1932686615
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Entity Type | Organization
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Legal Business Name | BAYSIDE LAKES PHARMACY LLC
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Dates
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Enumeration Date | 07/25/2018
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Last Update Date | 12/21/2018
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Provider Practice Location Address
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Address Line | 1850 ELDRON BLVD SE STE 7
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City | PALM BAY
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State | FL
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Zip | 32909-6870
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Country | US
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Telephone | 321-308-0303
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Fax | 321-308-0310
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Provider Business Mailing Address
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Address Line | 1850 ELDRON BLVD SE
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City | PALM BAY
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State | FL
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Zip | 32909-6870
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Country | US
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Telephone | 321-308-0303
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Fax | 321-308-0310
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Authorized Official
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Title or Position | OWNER
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Name | MRS. SUSAN ELIZABETH MACDONALD
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Credential |
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Telephone | 321-308-0303
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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 | 3336C0004X
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Taxonomy Name | Compounding 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 | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH31554
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License Number State | FL
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