| Organization Name: | LAKE REGIONAL MEDICAL MANAGEMENT |
| NPI Number: | 1407960479 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | STACIE LING (PHARMACY OPERATIONS MANAGER) |
| Mailing Address: | 1930 N Business Route 5 Unit 1c Camdenton |
| State: | MO US |
| Postal Code: | 650202659 |
| Phone Number: | 5733462300 |
| Fax Number: | 5733468409 |
| NPI Enumeration Date: | 08/18/2006 |
| NPI Last Update Date: | 12/02/2015 |
| 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 |