Provider Demographics
NPI:1376731547
Name:LAKEWAY PHARMACY
Entity Type:Organization
Organization Name:LAKEWAY PHARMACY
Other - Org Name:LAKEWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANG
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:865-406-4942
Mailing Address - Street 1:460 MEDICAL PARK DR
Mailing Address - Street 2:STE 101
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5782
Mailing Address - Country:US
Mailing Address - Phone:865-988-9858
Mailing Address - Fax:865-988-9859
Practice Address - Street 1:460 MEDICAL PARK DR
Practice Address - Street 2:STE 101
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5782
Practice Address - Country:US
Practice Address - Phone:865-988-9858
Practice Address - Fax:865-988-9859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4440690OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4440690OtherNCPDP PROVIDER IDENTIFICATION NUMBER