Provider Demographics
NPI:1679010763
Name:LAKE CITY PHARMACY, LLC
Entity type:Organization
Organization Name:LAKE CITY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE/ MANAGING EMPL
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ANGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-315-1200
Mailing Address - Street 1:33389 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-5926
Mailing Address - Country:US
Mailing Address - Phone:586-315-1200
Mailing Address - Fax:866-902-3981
Practice Address - Street 1:33389 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312
Practice Address - Country:US
Practice Address - Phone:586-315-1200
Practice Address - Fax:866-902-3981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MI5301011132333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy