Organization
EAGLE LAKE PHARMACY INC
Active
Other names
Eagle Lake Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
POLYCARP AGBARA (OWNER)
(863) 738-8002
Entity
Organization
Contact information
Practice address
5245 A U S HWY 98 N, SUITE A, LAKELAND, FL 33809
(863) 937-7992
(863) 937-7994
Mailing address
5245 A U S HWY 98 N, SUITE A, LAKELAND, FL 33809
(863) 937-7992
(863) 937-7994
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PH25608
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004712900
—
FL
01
—
2134900
PK
—
Enumeration date
04/04/2012
Last updated
11/23/2016
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