| Entity Name: | BAYSIDE LAKES PHARMACY LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Company |
| Status: | Active |
| Date Filed: | 15 Jun 2018 (7 years ago) |
| Document Number: | L18000147834 |
| FEI/EIN Number | 83-0938916 |
| Address: | 1850 ELDRON BLVD SE, SUITE 7, PALM BAY, FL 32909 |
| Mail Address: | 204 SOUTH PALM AVE, MELBOURNE BEACH, FL 32951 |
| ZIP code: | 32909 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1932686615 | 2018-07-25 | 2018-12-21 | 1850 ELDRON BLVD SE, PALM BAY, FL, 329096870, US | 1850 ELDRON BLVD SE STE 7, PALM BAY, FL, 329096870, US | |||||||||||||||||||||||||||||||||||||||
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| Phone | +1 321-308-0303 |
| Fax | 3213080310 |
Authorized person
| Name | MRS. SUSAN ELIZABETH MACDONALD |
| Role | OWNER |
| Phone | 3213080303 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH31554 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 3336C0004X - Compounding Pharmacy |
| Is Primary | No |
Other Provider Identifiers
| Issuer | BOARD OF PHARMACY |
| Number | PH31554 |
| State | FL |
| Issuer | MEDICAID |
| Number | 100868600 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MACDONALD, SUSAN E | Agent | 204 SOUTH PALM AVE, MELBOURNE BEACH, FL 32951 |
| Name | Role | Address |
|---|---|---|
| MACDONALD, SUSAN E | Manager | 204 SOUTH PALM AVE, MELBOURNE BEACH, FL 32951 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G18000080224 | BAYSIDE LAKES FAMILY PHARMACY | ACTIVE | 2018-07-25 | 2028-12-31 | No data | 1850 ELDRON BLVD, SUITE 7, PALM BAY, FL, 32909 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-08 |
| ANNUAL REPORT | 2023-04-24 |
| ANNUAL REPORT | 2022-04-29 |
| ANNUAL REPORT | 2021-04-20 |
| ANNUAL REPORT | 2020-05-06 |
| ANNUAL REPORT | 2019-03-22 |
| Florida Limited Liability | 2018-06-15 |
| Loan Number | Loan Funded Date | SBA Origination Office Code | Loan Delivery Method | Borrower Street Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| 2081747309 | 2020-04-29 | 0455 | PPP | 1850 Eldron Blvd, #7 STE 7, PALM BAY, FL, 32909-6870 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Date of last update: 17 Feb 2025
Sources: Florida Department of State
