MEDICARE: LAKER DRUG 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	332B00000X	Durable Medical Equipment & Medical Supplies	P06839	KY
2	3336C0003X	Community/Retail Pharmacy	P06839	KY

Other Identifiers

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

General Provider Information

NPI Number	:	1992718084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKER DRUG INC.

Provider Business Mailing Address
First Line	:	92 JOE T PETTY DR
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-8543
Country	:	US
Telephone Number	:	270-866-7787
Fax Number	:

Provider Business Practice Location Address
First Line	:	92 JOE T PETTY DR
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-8543
Country	:	US
Telephone Number	:	270-866-7787
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TIMOTHY D CARNES
Credential	:
Telephone Number	:	270-343-2336

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	03/17/2008

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Directions to “LAKER DRUG INC. ” Practice Location

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