Provider Demographics
NPI:1164734927
Name:RAGHAVENDRA PHARMACY INC
Entity Type:Organization
Organization Name:RAGHAVENDRA PHARMACY INC
Other - Org Name:LAKESIDE DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAGESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKHAMOORI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-631-6612
Mailing Address - Street 1:5431 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2921
Mailing Address - Country:US
Mailing Address - Phone:954-485-4903
Mailing Address - Fax:954-485-4948
Practice Address - Street 1:5431 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-2921
Practice Address - Country:US
Practice Address - Phone:954-485-4903
Practice Address - Fax:954-485-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH247273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5700605OtherNCPDP PROVIDER IDENTIFICATION NUMBER