Provider Demographics
NPI:1275986531
Name:CEDAR LAKE PHARMACY
Entity Type:Organization
Organization Name:CEDAR LAKE PHARMACY
Other - Org Name:LEE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:228-276-9009
Mailing Address - Street 1:917 DIVISION ST STE B
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-3001
Mailing Address - Country:US
Mailing Address - Phone:228-280-8931
Mailing Address - Fax:228-280-8915
Practice Address - Street 1:917 DIVISION ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-3001
Practice Address - Country:US
Practice Address - Phone:228-396-4412
Practice Address - Fax:228-396-4414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-21
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy