Provider Demographics
NPI:1568491413
Name:LAKESHORE APOTHACARE INC.
Entity Type:Organization
Organization Name:LAKESHORE APOTHACARE INC.
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:920-794-1225
Mailing Address - Street 1:1500 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3045
Mailing Address - Country:US
Mailing Address - Phone:920-794-1225
Mailing Address - Fax:920-794-7091
Practice Address - Street 1:1500 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3045
Practice Address - Country:US
Practice Address - Phone:920-794-1225
Practice Address - Fax:920-794-7091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33229600Medicaid
WI5124273OtherNCPDP #
WI5124273OtherNCPDP #
WIBT5998325OtherDEA #