Provider Demographics
NPI:1053762260
Name:NORTHLAKE PHARMACY LLC
Entity type:Organization
Organization Name:NORTHLAKE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST/AO
Authorized Official - Prefix:
Authorized Official - First Name:SALIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUFAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:561-562-2610
Mailing Address - Street 1:9091 N MILITARY TRL STE 17
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-5983
Mailing Address - Country:US
Mailing Address - Phone:561-619-9900
Mailing Address - Fax:561-619-9902
Practice Address - Street 1:9091 N MILITARY TRL STE 17
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-5983
Practice Address - Country:US
Practice Address - Phone:561-619-9900
Practice Address - Fax:561-619-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH302063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018799700Medicaid
2160865OtherPK