Organization
EAST LAKE PHARMACY INC
Active
Other names
Medicap Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD J KOSOBUCKI RPH (OWNER)
(814) 456-4108
Entity
Organization
Contact information
Practice address
1896 E LAKE RD, ERIE, PA 16511-1072
(814) 456-4108
(814) 456-4417
Mailing address
1896 E LAKE RD, ERIE, PA 16511-1072
(814) 456-4108
(814) 456-4417
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
PP481227
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0019341830001
—
PA
01
—
3981479
NCPDP #
PA
Enumeration date
08/16/2006
Last updated
03/07/2023
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