Provider Demographics
NPI:1790784346
Name:LAKE PLACID DRUG CO.
Entity Type:Organization
Organization Name:LAKE PLACID DRUG CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:STIDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:863-465-2291
Mailing Address - Street 1:224 E INTERLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-9603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:863-465-3977
Practice Address - Street 1:224 E INTERLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-9603
Practice Address - Country:US
Practice Address - Phone:863-465-2751
Practice Address - Fax:863-465-3977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0443400001Medicare ID - Type Unspecified