Provider Demographics
NPI:1023098803
Name:BIG LAKE PHARMACY INC
Entity type:Organization
Organization Name:BIG LAKE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRES
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH/CPH
Authorized Official - Phone:863-634-4002
Mailing Address - Street 1:203 SW PARK ST
Mailing Address - Street 2:STE B
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972-4160
Mailing Address - Country:US
Mailing Address - Phone:863-763-1339
Mailing Address - Fax:863-763-1487
Practice Address - Street 1:203 SW PARK ST
Practice Address - Street 2:STE B
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-4160
Practice Address - Country:US
Practice Address - Phone:863-763-1339
Practice Address - Fax:863-763-1487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336I0012X, 3336M0003X
FLPH187083336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031557500Medicaid
1096785OtherNCPDP PROVIDER IDENTIFICATION NUMBER