| Name: | Long's Lakeshore Discount Pharmacy, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Series Limited Liability Company |
| Status: | Exists |
| Date of registration: | 23 Jun 2015 (9 years ago) |
| Entity Number: | 000-338-682 |
| Register Number: | 000338682 |
| County: | Lee |
| Place of Formation: | Lee County |
| Registered Office Street Address: | 2250 WRIGHTS MILL ROADAUBURN, AL 36830 |
| Registered Office Street Address ZIP Code: | 36830 |
Activities
ALL PROPERTY
BOTH REAL AND PERSONAL
ANY RELATED ACTIVITIES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1386705440 | 2006-12-13 | 2016-01-21 | PO BOX 134, DADEVILLE, AL, 368530134, US | 221 E SOUTH ST, DADEVILLE, AL, 368531923, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 256-825-0063 |
| Fax | 2568255584 |
Authorized person
| Name | ERIC LONG |
| Role | OWNER/PRES |
| Phone | 2568250063 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | 110492 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 100002455 |
| State | AL |
| Issuer | NCPDP PROVIDER IDENTIFICATION NUMBER |
| Number | 0123721 |
| Name | Role | Address |
|---|---|---|
| LONG, ERIC D | Agent | 2250 WRIGHTS MILL ROADAUBURN, AL 36830 |
| Name | Role | Address |
|---|---|---|
| LONG, ERIC D | Organizer | 2250 WRIGHTS MILL ROADAUBURN, AL 36830 |
| LONG, MARY D | Organizer | 2250 WRIGHTS MILL ROADAUBURN, AL 36830 |
Date of last update: 03 Aug 2024
Sources: Alabama Secretary of State
