Provider Demographics
NPI:1013429711
Name:LAKE LANSING RX LLC
Entity Type:Organization
Organization Name:LAKE LANSING RX LLC
Other - Org Name:ABBEY PHARMACY - LANSING
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-751-7979
Mailing Address - Street 1:6689 ORCHARD LAKE RD # 168
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3404
Mailing Address - Country:US
Mailing Address - Phone:248-862-6148
Mailing Address - Fax:248-862-6132
Practice Address - Street 1:1540 LAKE LANSING RD STE 106
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3757
Practice Address - Country:US
Practice Address - Phone:517-455-7355
Practice Address - Fax:517-455-7523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010108173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013429711Medicaid
FSRX2177411OtherFLEXSCRIPT