1376731547 NPI number — LAKEWAY PHARMACY

Table of content: (NPI 1376731547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376731547 NPI number — LAKEWAY PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWAY PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376731547
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460 MEDICAL PARK DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
LENOIR CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37772-5782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-988-9858
Provider Business Mailing Address Fax Number:
865-988-9859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 MEDICAL PARK DR
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
LENOIR CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37772-5782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-988-9858
Provider Business Practice Location Address Fax Number:
865-988-9859
Provider Enumeration Date:
10/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEMAN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
MANG
Authorized Official Telephone Number:
865-406-4942

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  4433 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4440690 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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