Provider Demographics
NPI:1619067626
Name:LAKESHORE MEDIC PHARMACY
Entity Type:Organization
Organization Name:LAKESHORE MEDIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST RPH
Authorized Official - Phone:337-436-4388
Mailing Address - Street 1:2001 ENTERPRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601
Mailing Address - Country:US
Mailing Address - Phone:337-436-4388
Mailing Address - Fax:337-436-4389
Practice Address - Street 1:2001 ENTERPRISE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-436-4388
Practice Address - Fax:337-436-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171980001Medicare NSC