Provider Demographics
NPI:1467865337
Name:GREAT LAKES PHARMACY
Entity Type:Organization
Organization Name:GREAT LAKES PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MALKAMAKI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:440-352-2500
Mailing Address - Street 1:9500 MENTOR AVE
Mailing Address - Street 2:SUITE # 110
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8713
Mailing Address - Country:US
Mailing Address - Phone:440-352-2500
Mailing Address - Fax:440-352-2554
Practice Address - Street 1:9500 MENTOR AVE
Practice Address - Street 2:SUITE # 110
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8713
Practice Address - Country:US
Practice Address - Phone:440-352-2500
Practice Address - Fax:440-352-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-08
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy