Provider Demographics
NPI:1942227038
Name:LAKEIDE PHARMACY,INC.
Entity Type:Organization
Organization Name:LAKEIDE PHARMACY,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:STURT
Authorized Official - Suffix:
Authorized Official - Credentials:RPHBS
Authorized Official - Phone:312-567-7531
Mailing Address - Street 1:2218 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2126
Mailing Address - Country:US
Mailing Address - Phone:312-567-7531
Mailing Address - Fax:
Practice Address - Street 1:2218 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2126
Practice Address - Country:US
Practice Address - Phone:312-567-7531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid