Provider Demographics
NPI:1932347044
Name:LAKELAND PHARMACY PC
Entity type:Organization
Organization Name:LAKELAND PHARMACY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKIH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-231-2020
Mailing Address - Street 1:PO BOX 5185
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5589 E M36
Practice Address - Street 2:STE A10
Practice Address - City:PINCKNEY
Practice Address - State:MI
Practice Address - Zip Code:48169-9260
Practice Address - Country:US
Practice Address - Phone:810-231-2020
Practice Address - Fax:810-231-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010090673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2372441OtherNCPDP PROVIDER IDENTIFICATION NUMBER