Provider Demographics
NPI:1326151432
Name:EAST LAKE PHARMACY INC
Entity Type:Organization
Organization Name:EAST LAKE PHARMACY INC
Other - Org Name:MEDICAP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOSOBUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:814-456-4108
Mailing Address - Street 1:1896 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16511-1072
Mailing Address - Country:US
Mailing Address - Phone:814-456-4108
Mailing Address - Fax:814-456-4417
Practice Address - Street 1:1896 E LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16511-1072
Practice Address - Country:US
Practice Address - Phone:814-456-4108
Practice Address - Fax:814-456-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4812273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3981479OtherNCPDP #
PA0019341830001Medicaid
PABM8182076OtherDEA #
PA4736130001Medicare NSC