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LAKE SIDE PHARMACY, LLC

Details

Name: LAKE SIDE PHARMACY, LLC
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Exists
Date of registration: 24 Apr 2012 (13 years ago)
Entity Number: 000-052-542
Register Number: 000052542
Place of Formation: Cherokee County

Activities DEAL IN/WITH DRUGS/MEDICINES/GENERAL MERCHANDISE

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1093078768 2012-06-19 2017-01-03 10005 AL HIGHWAY 9 N, CEDAR BLUFF, AL, 359592231, US 10005 AL HIGHWAY 9 N, CEDAR BLUFF, AL, 359592231, US

Contacts

Phone +1 844-236-5360
Fax 8666094582

Authorized person

Name DR. STEPHEN WILSON
Role PHARMACIST IN CHARGE
Phone 8442365360

Taxonomy

Taxonomy Code 3336C0003X - Community/Retail Pharmacy
License Number 113926
State AL
Is Primary Yes

Other Provider Identifiers

Issuer ALABAMA PHARMACY LICENSE NUMBER
Number 113926
State AL

Agent

Name Role
HOPPER, CHAD A Agent

Organizer

Name Role Address
PUCKETT, ROBERT JOSEPH SR Organizer 113 HYCLIFF ROADROME, GA 30165
BOGUE, JAMES B JR Organizer 3565 WAYSIDE ROADKINGSTON, GA 30145

Date of last update: 31 Jul 2024

Sources: Alabama Secretary of State