# LAKE OF DECATUR INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** DALES SOUTHLAKE PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588613384
- **Authorized official:** DALE COLEE (PRESIDENT)
- **Authorized official phone:** (217) 429-5165

## Contact information

- **Practice address:** 245 W 1ST DR STE B, DECATUR, IL 62521-5381
- **Practice address phone:** (217) 429-5165
- **Practice address fax:** (217) 429-5172
- **Mailing address:** 245 W 1ST DR STE B, DECATUR, IL 62521-5381
- **Mailing address phone:** (217) 429-5165
- **Mailing address fax:** (217) 429-5172

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 54.015385 | IL | Yes |
| 3336L0003X | Long Term Care Pharmacy | — | NULL | — |
| 3336M0003X | Managed Care Organization Pharmacy | — | NULL | — |

## Other

- **Enumeration date:** 05/09/2006
- **Last updated:** 10/21/2021

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2021672 | PK | — |