Provider Demographics
NPI:1295258200
Name:LAKESHORE PHARMACY
Entity type:Organization
Organization Name:LAKESHORE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEARNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-783-6633
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-0959
Mailing Address - Country:US
Mailing Address - Phone:920-783-6633
Mailing Address - Fax:920-783-6804
Practice Address - Street 1:1721 SAEMANN AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-2342
Practice Address - Country:US
Practice Address - Phone:920-783-6633
Practice Address - Fax:920-783-6804
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESHORE COMMUNITY HEALTH CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9472423336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIFL6993491OtherDEA