Provider Demographics
NPI:1467465922
Name:LAKEWOOD PHARMACY LLC
Entity Type:Organization
Organization Name:LAKEWOOD PHARMACY LLC
Other - Org Name:REFUA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ITZHAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-454-3052
Mailing Address - Street 1:911 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2069
Mailing Address - Country:US
Mailing Address - Phone:732-942-9987
Mailing Address - Fax:732-810-0260
Practice Address - Street 1:911 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-2069
Practice Address - Country:US
Practice Address - Phone:732-942-9987
Practice Address - Fax:732-810-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006057003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8747717Medicaid
NJ8747709Medicaid
NJ8747717Medicaid