Provider Demographics
NPI:1689736746
Name:LIVONIA LAKEVILLE PHARMACY INC
Entity Type:Organization
Organization Name:LIVONIA LAKEVILLE PHARMACY INC
Other - Org Name:LIVONIA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-346-5615
Mailing Address - Street 1:PO BOX 414
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14480-0414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5975 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:NY
Practice Address - Zip Code:14480-0414
Practice Address - Country:US
Practice Address - Phone:585-346-5615
Practice Address - Fax:585-346-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0243333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1944178Medicaid
2064266OtherPK
2064266OtherPK