| Entity Name: | LAKE TOWN PHARMACY, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 01 Dec 2014 (10 years ago) |
| Document Number: | L14000183159 |
| FEI/EIN Number | 47-2416827 |
| Address: | 2020 N CR 470, Unit - B, LAKE PANASOFFKEE, FL 33538 |
| Mail Address: | 2020 N CR 470, Unit - B, LAKE PANASOFFKEE, FL 33538 |
| ZIP code: | 33538 |
| County: | Sumter |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1093186546 | 2015-10-09 | 2021-09-24 | 2020 CR N 470 UNIT B, LAKE PANASOFFKEE, FL, 33538, US | 2020 CR N 470 UNIT B, LAKE PANASOFFKEE, FL, 33538, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 352-444-2055 |
| Fax | 3525694768 |
Authorized person
| Name | RAJASEKARAN MANI |
| Role | OWNER, AO, PHCY MANAGER, PIC |
| Phone | 2392460796 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH28934 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | PK |
| Number | 2154679 |
| Issuer | MEDICAID |
| Number | 016675400 |
| State | FL |
| Name | Role |
|---|---|
| MAITRI & ASSOCIATES, LLC | Agent |
| Name | Role | Address |
|---|---|---|
| MANI, RAJASEKARAN | MANAGING MEMBER | 2020 N CR 470, Unit - B, LAKE PANASOFFKEE, FL 33538 |
| KANAKARAJAN, SUNDARAM | MANAGING MEMBER | 2020 N CR 470 UNIT B, LAKE PANASOFFKEE, FL 33538 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G16000023180 | BENZER PHARMACY | EXPIRED | 2016-03-03 | 2021-12-31 | No data | 2044 COUNTY ROAD 470, LAKE PANASOFFKEE, FL, 33538 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| REGISTERED AGENT ADDRESS CHANGED | 2021-01-07 | 8270 Woodland Center Blvd, TAMPA, FL 33614 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-01-29 | 2020 N CR 470, Unit - B, LAKE PANASOFFKEE, FL 33538 | No data |
| CHANGE OF MAILING ADDRESS | 2018-01-29 | 2020 N CR 470, Unit - B, LAKE PANASOFFKEE, FL 33538 | No data |
| Name | Date |
|---|---|
| AMENDED ANNUAL REPORT | 2024-03-28 |
| ANNUAL REPORT | 2024-03-24 |
| ANNUAL REPORT | 2023-03-14 |
| ANNUAL REPORT | 2022-02-03 |
| ANNUAL REPORT | 2021-01-07 |
| AMENDED ANNUAL REPORT | 2020-04-05 |
| AMENDED ANNUAL REPORT | 2020-01-24 |
| ANNUAL REPORT | 2020-01-02 |
| ANNUAL REPORT | 2019-04-08 |
| ANNUAL REPORT | 2018-01-29 |
Date of last update: 21 Jan 2025
Sources: Florida Department of State
