Provider Demographics
NPI:1609386119
Name:LAKESIDE PHARMACY LLC
Entity Type:Organization
Organization Name:LAKESIDE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILAGRO
Authorized Official - Middle Name:BEATRIZ
Authorized Official - Last Name:AMATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-846-8818
Mailing Address - Street 1:1194 HILLSBORO MILE # E
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-1531
Mailing Address - Country:US
Mailing Address - Phone:954-629-0324
Mailing Address - Fax:928-846-8817
Practice Address - Street 1:1960 MESQUITE AVE STE E
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5783
Practice Address - Country:US
Practice Address - Phone:928-846-8818
Practice Address - Fax:928-846-8817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy