Provider Demographics
NPI:1407199169
Name:LAKE ELLA PHARMACY
Entity Type:Organization
Organization Name:LAKE ELLA PHARMACY
Other - Org Name:LAKE ELLA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PIC
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MENSAH-MAMFO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-284-4660
Mailing Address - Street 1:4313 MAYLOR LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5773
Mailing Address - Country:US
Mailing Address - Phone:850-824-4660
Mailing Address - Fax:850-727-8736
Practice Address - Street 1:2525 S MONROE ST STE 6
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-6353
Practice Address - Country:US
Practice Address - Phone:850-727-8736
Practice Address - Fax:850-727-8736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH267793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139664OtherPK