Provider Demographics
NPI:1316020589
Name:OCEAN LAKES PHARMACY INC
Entity Type:Organization
Organization Name:OCEAN LAKES PHARMACY INC
Other - Org Name:OCEAN LAKES PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:848-238-5159
Mailing Address - Street 1:1415 HWY 17 BUSINESS N
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575
Mailing Address - Country:US
Mailing Address - Phone:843-238-5159
Mailing Address - Fax:843-238-8270
Practice Address - Street 1:1415 HWY 17 BUSINESS N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575
Practice Address - Country:US
Practice Address - Phone:843-238-5159
Practice Address - Fax:843-238-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
SC500047213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC747216Medicaid
SCEN2106Medicaid
2088907OtherPK
SC611804Medicaid