Provider Demographics
NPI:1801185574
Name:LAKESIDE PHARMACY INC.
Entity Type:Organization
Organization Name:LAKESIDE PHARMACY INC.
Other - Org Name:LAKESIDE PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:LECHAK
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:501-262-5400
Mailing Address - Street 1:998 SHADY GROVE RD STE 1H
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-8094
Mailing Address - Country:US
Mailing Address - Phone:501-262-5400
Mailing Address - Fax:501-262-5404
Practice Address - Street 1:998 SHADY GROVE RD UNIT 1-H
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-8094
Practice Address - Country:US
Practice Address - Phone:501-262-5400
Practice Address - Fax:501-262-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR206463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186438407Medicaid
2129891OtherPK