Provider Demographics
NPI:1932686615
Name:BAYSIDE LAKES PHARMACY LLC
Entity Type:Organization
Organization Name:BAYSIDE LAKES PHARMACY LLC
Other - Org Name:BAYSIDE LAKES FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-308-0303
Mailing Address - Street 1:1850 ELDRON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6870
Mailing Address - Country:US
Mailing Address - Phone:321-308-0303
Mailing Address - Fax:321-308-0310
Practice Address - Street 1:1850 ELDRON BLVD SE STE 7
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-6870
Practice Address - Country:US
Practice Address - Phone:321-308-0303
Practice Address - Fax:321-308-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
FLPH315543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH31554OtherBOARD OF PHARMACY
FL100868600Medicaid