Provider Demographics
NPI:1205591054
Name:LAKE CITY DRUG LLC
Entity type:Organization
Organization Name:LAKE CITY DRUG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-351-2697
Mailing Address - Street 1:210 COBEAN BLVD # 10
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72437-9704
Mailing Address - Country:US
Mailing Address - Phone:870-237-8215
Mailing Address - Fax:
Practice Address - Street 1:210 COBEAN BLVD # 10
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:AR
Practice Address - Zip Code:72437-9704
Practice Address - Country:US
Practice Address - Phone:870-237-8215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy