Provider Demographics
NPI:1942221262
Name:LAKE HOLIDAY DRUGS INC
Entity Type:Organization
Organization Name:LAKE HOLIDAY DRUGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:3RD PARTY COORD
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-987-6468
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:915 S HALLECK
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-0662
Mailing Address - Country:US
Mailing Address - Phone:219-987-6468
Mailing Address - Fax:219-987-7226
Practice Address - Street 1:10064 N 600 E
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8536
Practice Address - Country:US
Practice Address - Phone:219-345-2200
Practice Address - Fax:219-345-2411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100187060Medicaid
1520813OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IN251490Medicare PIN
IN0579030001Medicare NSC