Provider Demographics
NPI:1225048978
Name:LAKESHORE PHARMACIES, INC.
Entity Type:Organization
Organization Name:LAKESHORE PHARMACIES, INC.
Other - Org Name:ALLEGAN COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:269-673-4188
Mailing Address - Street 1:115 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1301
Mailing Address - Country:US
Mailing Address - Phone:269-673-4188
Mailing Address - Fax:269-673-6773
Practice Address - Street 1:115 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1301
Practice Address - Country:US
Practice Address - Phone:269-673-4188
Practice Address - Fax:269-673-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010055983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2349694Medicaid
MI0002808093Medicaid
MI5301005598OtherSTATE PHARMACY LICENSE #
MI0395730002Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER