LAKE OF DECATUR INC (NPI# 1588613384) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1588613384 |
| Entity Type | Organization |
| Organization Name | LAKE OF DECATUR INC |
| Other Organization Name | DALES SOUTHLAKE PHARMACY |
| Practice Address |
245 W 1st Dr Decatur IL 62521-5299 |
| Practice Telephone | 2174295165 |
| Practice Fax Number | 2174295172 |
| Mailing Telephone | 2174295165 |
| Mailing Fax Number | 2174295172 |
| Enumeration Date | 2006-05-09 |
| Last Update Date | 2016-04-05 |
| Authorized Official Name | DALE COLEE (PRESIDENT) |
| Authorized Official Telephone | 2174295165 |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 333600000X | Pharmacy | Suppliers | ||
| N | 3336L0003X |
Pharmacy Specialization: Long Term Care Pharmacy |
Suppliers | ||
| N | 3336M0003X |
Pharmacy Specialization: Managed Care Organization Pharmacy |
Suppliers | ||
| Y | 3336C0003X |
Pharmacy Specialization: Community/Retail Pharmacy |
54.015385 | IL | Suppliers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| PK | 2021672 | 01 |
| Other Name | Type Code |
|---|---|
| DALES SOUTHLAKE PHARMACY | Doing Business As Name - Organization |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1386096170 | Lake of Decatur Inc | Pharmacy | 320 E Central Ave, Decatur, IL 62521-4665 | 2016-07-06 |
| Street Address |
245 W 1ST DR |
| City | DECATUR |
| State | IL |
| Zip Code | 62521-5299 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1053927988 | Caleb David Braasch | Pharmacist | 1818 South Airport Rd, Decatur, IL 62521 | 2020-09-16 |
| 1295390490 | Crossing Recovery Center | Substance Abuse Rehabilitation Facility | Crossing Recovery Center, 495 East Central Ave, Decatur, IL 62521 | 2019-05-03 |
| 1396300638 | Crossing Recovery Center | Substance Abuse Rehabilitation Facility | 495 E Central Ave, Decatur, IL 62521 | 2019-05-02 |
| 1679138911 | Crossing Recovery Center | Substance Abuse Rehabilitation Facility | 495 East Central Ave, Decatur, IL 62521 | 2019-05-02 |
| 1154848034 | Zack Shaw | Physical Therapist | 4855-57 East 36, Decatur, IL 62521 | 2017-08-23 |
| 1790032852 | Prashant Morolia | Family Medicine | 4775 E Maryland St, Decatur, IL 62521 | 2012-08-08 |
| 1003188913 | Evergreen Place Decatur, LLC | Assisted Living Facility | 4825 E Evergreen Court, Decatur, IL 62521 | 2012-02-08 |
| 1104133099 | Suzette Marie Shafer | Occupational Therapy Assistant | 1790 S. Fairview Ave., Decatur, IL 62521 | 2010-09-13 |
| 1467784090 | Community Health Improvement Center | Clinic/Center | 1221 East Condit Street, Decatur, IL 62521 | 2010-02-08 |
| 1982839056 | Kelly Clark Dds PC | Dentist | 3737 Us Rt 36 E, Decatur, IL 62521 | 2009-05-19 |
| Find all providers in zip 62521 | ||||
| Taxonomy Code | 3336C0003X |
| Grouping | Suppliers |
| Classification | Pharmacy |
| Specialization | Community/Retail Pharmacy |
| A pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes. |
| Notes: Source: Developed by National Council for Prescription Drug Programs (NCPDP), National Home Infusion Association (NHIA), and Pharmacist Services Technical Advisory Coalition (PSTAC) [1/1/2006: new] |
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| 1912476466 | Positive Impact Health Centers, Inc. | Pharmacy | 523 Church Street, Suite B, Decatur, GA 30030 | 2018-11-14 |
| 1730605734 | Ganesha Rx Care Group 2, LLC | Pharmacy | 2801 N Decatur Rd Ste 130, Decatur, GA 30033-5949 | 2017-08-21 |
| 1255853784 | Anchor Rx Pharmacy | Pharmacy | 2139 Lawrenceville Hwy, Decatur, GA 30033-4321 | 2017-07-17 |
| 1841532546 | Priceville Pharmacy LLC | Pharmacy | 2941 Point Mallard Pkwy, Suite A, Decatur, AL 35603 | 2013-03-20 |
| 1508106121 | Murks Village Market Inc | Pharmacy | 108b East Delaware Street, Decatur, MI 49045 | 2013-02-19 |
| 1902162548 | Apothecary Sales Inc | Pharmacy | 3220 Highway 31 S Ste A2, Decatur, AL 35603-1731 | 2012-04-09 |
| 1760780233 | Rite Aid | Pharmacy | 1526 6th Av. Se, Decatur, AL 35601-4561 | 2011-03-08 |
| 1285943829 | Victory Pharmacy | Pharmacy | 2280 E William St, Decatur, IL 62521-1528 | 2010-09-30 |
| Find all providers in DECATUR | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.