Provider Demographics
NPI:1477850931
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:PHARMACIST-IN-CHARGE/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:CATTANEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-844-0777
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-0459
Mailing Address - Country:US
Mailing Address - Phone:406-844-0777
Mailing Address - Fax:406-844-0776
Practice Address - Street 1:7100 HWY 93 SOUTH, SUITE A
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922
Practice Address - Country:US
Practice Address - Phone:406-844-0777
Practice Address - Fax:406-844-0776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MT13263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2783721OtherNCPDP PROVIDER IDENTIFICATION NUMBER