Provider Demographics
NPI:1174684468
Name:BTB LAKEWAY INC
Entity Type:Organization
Organization Name:BTB LAKEWAY INC
Other - Org Name:LAKEWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:T
Authorized Official - Last Name:BROOKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:512-261-6567
Mailing Address - Street 1:1202 LAKEWAY DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4473
Mailing Address - Country:US
Mailing Address - Phone:512-261-6567
Mailing Address - Fax:512-261-6017
Practice Address - Street 1:1202 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4473
Practice Address - Country:US
Practice Address - Phone:512-261-6567
Practice Address - Fax:512-261-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX153543336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0684839Medicaid