Provider Demographics
NPI:1003976028
Name:LAKE AREA PHARMACY
Entity Type:Organization
Organization Name:LAKE AREA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CLOUD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:337-721-1931
Mailing Address - Street 1:1004 FORTUNE RD STE 6
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5793
Mailing Address - Country:US
Mailing Address - Phone:337-450-3052
Mailing Address - Fax:337-450-3053
Practice Address - Street 1:1004 FORTUNE RD STE 6
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5793
Practice Address - Country:US
Practice Address - Phone:337-450-3052
Practice Address - Fax:337-450-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5129-IR333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1271080Medicaid
LA4883750001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER