1912146507 NPI number — LAKELAND CITY PHARMACY INC

Table of content: (NPI 1912146507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912146507 NPI number — LAKELAND CITY PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKELAND CITY PHARMACY INC
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:
1912146507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33682-7175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 E BLUE HERON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVIERA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33404-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-818-2233
Provider Business Practice Location Address Fax Number:
855-225-1063
Provider Enumeration Date:
02/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BANJOKO
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
212-257-0225

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PH23820 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2118838 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 104357200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116564200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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