Provider Demographics
NPI:1326605452
Name:LAKE COUNTRY PHARMACY LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY PHARMACY LLC
Other - Org Name:LAKE COUNTRY COMPOUNDING & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:762-777-7001
Mailing Address - Street 1:121 HARMONY XING STE 3
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-9573
Mailing Address - Country:US
Mailing Address - Phone:762-777-7001
Mailing Address - Fax:762-777-7002
Practice Address - Street 1:121 HARMONY XING STE 3
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9573
Practice Address - Country:US
Practice Address - Phone:762-777-7001
Practice Address - Fax:762-777-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-23
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy