Provider Demographics
NPI:1780468884
Name:LAKESIDE PHARMACY LLC
Entity type:Organization
Organization Name:LAKESIDE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:HARRIGAN
Authorized Official - Last Name:PREZIOSO
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, PHARMD
Authorized Official - Phone:936-448-6337
Mailing Address - Street 1:16955 WALDEN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-3227
Mailing Address - Country:US
Mailing Address - Phone:936-448-6337
Mailing Address - Fax:936-448-6338
Practice Address - Street 1:16955 WALDEN RD STE 100
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-3227
Practice Address - Country:US
Practice Address - Phone:936-448-6337
Practice Address - Fax:936-448-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy