MEDICARE: LAKE PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PH6551	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1033884	OTHER		OTHER ID NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972592889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 977
Second Line	:
City	:	BELLE GLADE
State	:	FL
Zip	:	33430-0977
Country	:	US
Telephone Number	:	561-996-0200
Fax Number	:	561-996-0201

Provider Business Practice Location Address
First Line	:	25 MARTIN LUTHER KING JR BLVD
Second Line	:	SUITE 3
City	:	BELLE GLADE
State	:	FL
Zip	:	33430-4044
Country	:	US
Telephone Number	:	561-996-0200
Fax Number	:	561-996-0201

Authorized Official
Title or Position	:	RPA
Name	:	ROBERT STORY
Credential	:	RPA
Telephone Number	:	561-996-0200

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	08/18/2011

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Directions to “LAKE PHARMACY INC ” Practice Location

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