Provider Demographics
NPI:1043405459
Name:LAKE BRANDT PHARMACY INC
Entity Type:Organization
Organization Name:LAKE BRANDT PHARMACY INC
Other - Org Name:LAKE BRANDT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-643-2550
Mailing Address - Street 1:1007 E HWY 150 WEST
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358
Mailing Address - Country:US
Mailing Address - Phone:336-643-2550
Mailing Address - Fax:336-643-2115
Practice Address - Street 1:1007 E HWY 150 WEST
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:NC
Practice Address - Zip Code:27358
Practice Address - Country:US
Practice Address - Phone:336-643-2550
Practice Address - Fax:336-643-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC099073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3409100OtherNCPDP PROVIDER IDENTIFICATION NUMBER