| Organization Name: | LAKESIDE PHARMACY LLC |
| NPI Number: | 1013239417 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KIM PREZIOSO (PRESIDENT/PHARM-IN-CHARGE) |
| Mailing Address: | 16955 Walden Rd Ste 100 Montgomery |
| State: | TX US |
| Postal Code: | 773563227 |
| Phone Number: | 9364486337 |
| Fax Number: | 9364486338 |
| NPI Enumeration Date: | 02/26/2010 |
| NPI Last Update Date: | 04/07/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336C0004X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | Compounding Pharmacy |
| Taxonomy Definition: | A pharmacy that specializes in the preparation of components into a drug preparation as the result of a Practitioner |