Provider Demographics
NPI:1215189311
Name:LAKESIDE FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:LAKESIDE FAMILY PHARMACY LLC
Other - Org Name:LAKESIDE FAMILY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:APOLLON
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTINIDES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-781-1450
Mailing Address - Street 1:1505 NORTHSIDE BLVD
Mailing Address - Street 2:STE 1600
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7623
Mailing Address - Country:US
Mailing Address - Phone:770-781-1450
Mailing Address - Fax:770-781-1455
Practice Address - Street 1:1505 NORTHSIDE BLVD
Practice Address - Street 2:STE 1600
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7623
Practice Address - Country:US
Practice Address - Phone:770-781-1450
Practice Address - Fax:770-781-1455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0095173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1157862OtherNCPDP PROVIDER IDENTIFICATION NUMBER