Provider Demographics
NPI:1881609410
Name:LAKEWOOD APOTHECARY AND NATURAL HEALTH CENTER INC
Entity type:Organization
Organization Name:LAKEWOOD APOTHECARY AND NATURAL HEALTH CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUEGNO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:716-763-0016
Mailing Address - Street 1:130 CHAUTAUQUA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1241
Mailing Address - Country:US
Mailing Address - Phone:716-763-0016
Mailing Address - Fax:716-763-0076
Practice Address - Street 1:130 CHAUTAUQUA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1241
Practice Address - Country:US
Practice Address - Phone:716-763-0016
Practice Address - Fax:716-763-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0275283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067651OtherPK
NY02756967Medicaid
NY02756967Medicaid