| Name: | Lake Pharmacy, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 01 Oct 2014 (10 years ago) (Companies founded in October 2014) |
| Entity Number: | 000-319-489 |
| Register Number: | 000319489 |
| ZIP code: | 36022 (Companies in Elmore, 36022) |
| County: | Elmore |
| Place of Formation: | Elmore County |
| Registered Office Street Address: | 95 LIGHTWOOD ROADDEATSVILLE, AL 36022 |
Activities
OWN AND OPERATE A RETAIL PHARMACY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1437209616 | 2007-01-11 | 2017-02-28 | 95 LIGHTWOOD RD, MAIN ST SLAPOUT, DEATSVILLE, AL, 360223494, US | 95 LIGHTWOOD RD, MAIN ST SLAPOUT, DEATSVILLE, AL, 360223494, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 334-569-2112 |
| Fax | 3345691143 |
Authorized person
| Name | ROBERT GOLDEN |
| Role | OWNER |
| Phone | 3345692112 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | 105942 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 100001378 |
| State | AL |
| Issuer | PK |
| Number | 2151251 |
| Name | Role | Address |
|---|---|---|
| GOLDEN, ROBERT L JR | Organizer | 95 LIGHTWOOD ROADDEATSVILLE, AL 36022 |
| Name | Role | Address |
|---|---|---|
| GOLDEN, ROBERT L JR | Agent | 95 LIGHTWOOD ROADDEATSVILLE, AL 36022 |
Date of last update: 03 Aug 2024
Sources: Alabama Secretary of State
