Provider Demographics
NPI:1558404442
Name:LAKE PLACID PHARMACY INC
Entity Type:Organization
Organization Name:LAKE PLACID PHARMACY INC
Other - Org Name:LAKE PLACID DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:863-385-5588
Mailing Address - Street 1:6360 US 27 N
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-1225
Mailing Address - Country:US
Mailing Address - Phone:863-385-5588
Mailing Address - Fax:
Practice Address - Street 1:224 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9603
Practice Address - Country:US
Practice Address - Phone:863-385-5588
Practice Address - Fax:863-465-3977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH218933336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1021031OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL031423400Medicaid
1021031OtherOTHER ID NUMBER