Provider Demographics
NPI:1346261237
Name:LAKE CITY PHARMACY INC
Entity Type:Organization
Organization Name:LAKE CITY PHARMACY INC
Other - Org Name:LAKE CITY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:ROSENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:386-758-6770
Mailing Address - Street 1:376 SW ALACHUA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5201
Mailing Address - Country:US
Mailing Address - Phone:386-758-3460
Mailing Address - Fax:386-758-3462
Practice Address - Street 1:376 SW ALACHUA AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5201
Practice Address - Country:US
Practice Address - Phone:386-758-3460
Practice Address - Fax:386-758-3462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH21845332B00000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031645801Medicaid
1018616OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL031645801Medicaid