Provider Demographics
NPI:1518328038
Name:LAKE SHORE DRUGS LLC
Entity Type:Organization
Organization Name:LAKE SHORE DRUGS LLC
Other - Org Name:MIKE'S PHARMACY II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHALENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERUKURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-255-0099
Mailing Address - Street 1:3820 MOUNTAIN RD UNIT G
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2027
Mailing Address - Country:US
Mailing Address - Phone:410-255-0099
Mailing Address - Fax:410-255-0799
Practice Address - Street 1:3820 MOUNTAIN RD UNIT G
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2027
Practice Address - Country:US
Practice Address - Phone:410-255-0099
Practice Address - Fax:410-255-0799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MDP07151333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159782OtherPK