Provider Demographics
NPI:1437281847
Name:LAKESIDE PHARMACY, LLC
Entity Type:Organization
Organization Name:LAKESIDE PHARMACY, LLC
Other - Org Name:LAKESIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:APOLLON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CONSTANTINIDES
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:770-205-0290
Mailing Address - Street 1:1100 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6012
Mailing Address - Country:US
Mailing Address - Phone:770-205-0290
Mailing Address - Fax:770-205-7386
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6012
Practice Address - Country:US
Practice Address - Phone:770-205-0290
Practice Address - Fax:770-205-7386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0085173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00913811AMedicaid
GA00913811AMedicaid