Provider Demographics
NPI:1437824117
Name:LAKE AVE PHARMA LLC
Entity Type:Organization
Organization Name:LAKE AVE PHARMA LLC
Other - Org Name:LAKE AVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-965-3034
Mailing Address - Street 1:130 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10703-2713
Mailing Address - Country:US
Mailing Address - Phone:914-965-3034
Mailing Address - Fax:914-965-4176
Practice Address - Street 1:130 LAKE AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10703-2713
Practice Address - Country:US
Practice Address - Phone:914-965-3034
Practice Address - Fax:914-965-4176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy