Provider Demographics
NPI:1487667903
Name:LAKEVIEW PHARMACY INC
Entity Type:Organization
Organization Name:LAKEVIEW PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEHRKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-339-2424
Mailing Address - Street 1:114 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS
Mailing Address - State:WI
Mailing Address - Zip Code:54555-1221
Mailing Address - Country:US
Mailing Address - Phone:715-339-2424
Mailing Address - Fax:715-339-4027
Practice Address - Street 1:114 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PHILLIPS
Practice Address - State:WI
Practice Address - Zip Code:54555-1221
Practice Address - Country:US
Practice Address - Phone:715-339-2424
Practice Address - Fax:715-339-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56710423336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33111000Medicaid
0850390001Medicare NSC
0850390001Medicare ID - Type Unspecified