| 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
| 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 | |||||||||||||||||||||||||
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| 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 |
| Name | Role |
|---|---|
| HOPPER, CHAD A | Agent |
| 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
