Provider Demographics
NPI:1568509974
Name:EAGLE LAKE DRUGSTORE
Entity Type:Organization
Organization Name:EAGLE LAKE DRUGSTORE
Other - Org Name:EAGLE LAKE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ZARATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-234-2502
Mailing Address - Street 1:702 S MCCARTY AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77434-3212
Mailing Address - Country:US
Mailing Address - Phone:979-234-2502
Mailing Address - Fax:979-234-5005
Practice Address - Street 1:702 S MCCARTY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:TX
Practice Address - Zip Code:77434-3212
Practice Address - Country:US
Practice Address - Phone:979-234-2502
Practice Address - Fax:979-234-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX117543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095769OtherPK
TX108467501Medicaid