Provider Demographics
NPI:1952407215
Name:LAKE MARTIN PHARMACY
Entity Type:Organization
Organization Name:LAKE MARTIN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:RANDAL
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:256-825-7822
Mailing Address - Street 1:301 MARIARDEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-6254
Mailing Address - Country:US
Mailing Address - Phone:256-825-7822
Mailing Address - Fax:256-827-0802
Practice Address - Street 1:301 MARIARDEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-6254
Practice Address - Country:US
Practice Address - Phone:256-825-7822
Practice Address - Fax:256-827-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1128563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5904130001Medicare NSC