Active NPI
Eagle Lake Pharmacy Inc
Doing business as Eagle Lake Pharmacy
- Community/Retail Pharmacy
- Lakeland, FL
National Provider Identifier
1023374063
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- PH25608
- Legal business name
- EAGLE LAKE PHARMACY INC
- Doing business as
- Eagle Lake Pharmacy
- Practice address
- 5245 A U S Hwy 98 N
Suite a
Lakeland, FL 33809 - Phone
- (863) 937-7992
- Fax
- (863) 937-7994
- NPI assigned
- Apr 4, 2012
- Last updated
- Nov 23, 2016
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Polycarp Agbara
- Title
- Owner
- Phone
- (863) 738-8002
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | NU | ||
| Community/Retail Pharmacy | 3336C0003X | PH25608 | FL | Primary |
Addresses
Primary practice location
5245 A U S Hwy 98 N
Suite a
Lakeland, FL 33809
Mailing address
5245 A U S Hwy 98 N
Suite a
Lakeland, FL 33809
Phone (863) 937-7992
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 004712900 | Medicaid | FL | |
| 2134900 | Other | PK |
Other names 1
- Eagle Lake Pharmacy
National Provider Directory
National Provider DirectoryLocations
5245 US Highway 98 N
Ste A
Lakeland, FL 33809
Phone (863) 937-7992
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1333497600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1479859200000",
"number": "1023374063",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5245 A U S HWY 98 N",
"address_2": "SUITE A",
"city": "LAKELAND",
"state": "FL",
"postal_code": "33809",
"telephone_number": "863-937-7992",
"fax_number": "863-937-7994"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5245 A U S HWY 98 N",
"address_2": "SUITE A",
"city": "LAKELAND",
"state": "FL",
"postal_code": "33809",
"telephone_number": "863-937-7992",
"fax_number": "863-937-7994"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "EAGLE LAKE PHARMACY INC",
"organizational_subpart": "NO",
"enumeration_date": "2012-04-04",
"last_updated": "2016-11-23",
"status": "A",
"authorized_official_last_name": "AGBARA",
"authorized_official_first_name": "POLYCARP",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "863-738-8002"
},
"taxonomies": [
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": "NU",
"license": null,
"primary": false
},
{
"code": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": "FL",
"license": "PH25608",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "004712900",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2134900",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Eagle Lake Pharmacy",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lakeland, FL
- Dynamic Home Health Care Service LLC (Dynamic Home Care Service)
- Dynamic Therapy Inc
- Dynamiks Home Care Inc
- E & M Medical Group PA
- Jennifer Eady, LDO
- Eagle Pharmacy LLC (Ryaltris Direct)
- Eagle Pharmacy LLC (Combogesic Direct)
- Eagle Pharmacy LLC (VandaRx)
- Eagle Pharmacy LLC
- Eagle Pharmacy LLC (LUCEMYRA Rx Connect)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.