Organization
LAKESIDE PHARMACY LLC
Active
Other names
Lakeside Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
KIM PREZIOSO (PRESIDENT/PHARM-IN-CHARGE)
(936) 827-3766
Entity
Organization
Contact information
Practice address
16955 WALDEN RD STE 100, MONTGOMERY, TX 77356-3227
(936) 448-6337
(936) 448-6338
Mailing address
16955 WALDEN RD, SUITE 100, MONTGOMERY, TX 77356-3220
(936) 448-6337
(936) 448-6338
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
26843
TX
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4555186
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
02/26/2010
Last updated
04/07/2010
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