Provider Demographics
NPI:1891959003
Name:LAKES AREA PHARMACY
Entity Type:Organization
Organization Name:LAKES AREA PHARMACY
Other - Org Name:DURA MED, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CRESTA
Authorized Official - Middle Name:H
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-756-8550
Mailing Address - Street 1:608 BUCHANAN DR
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-2306
Mailing Address - Country:US
Mailing Address - Phone:512-756-8550
Mailing Address - Fax:
Practice Address - Street 1:608 BUCHANAN DR
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-2306
Practice Address - Country:US
Practice Address - Phone:512-756-8550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0068661332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX014179801Medicaid
282501OtherSCOTT AND WHITE
TX1145360001Medicare NSC