| Entity Name: | EAGLE LAKE PHARMACY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Inactive |
| Date Filed: | 07 Mar 2011 (14 years ago) |
| Date of dissolution: | 27 Sep 2019 (5 years ago) |
| Last Event: | ADMIN DISSOLUTION FOR ANNUAL REPORT |
| Event Date Filed: | 27 Sep 2019 (5 years ago) |
| Document Number: | P11000023050 |
| FEI/EIN Number | 275477007 |
| Address: | 5245 US HWY 98, LAKELAND, FL, 33809, US |
| Mail Address: | 5245 US HWY 98, LAKELAND, FL, 33809, US |
| ZIP code: | 33809 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1023374063 | 2012-04-04 | 2016-11-23 | 5245 A U S HWY 98 N, SUITE A, LAKELAND, FL, 33809, US | 5245 A U S HWY 98 N, SUITE A, LAKELAND, FL, 33809, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 863-937-7992 |
| Fax | 8639377994 |
Authorized person
| Name | POLYCARP AGBARA |
| Role | OWNER |
| Phone | 8637388002 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH25608 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 004712900 |
| State | FL |
| Issuer | PK |
| Number | 2134900 |
| Name | Role | Address |
|---|---|---|
| Blanchard Ted | Agent | 5245 US HWY 98 N STE A, LAKELAND, FL, 33809 |
| Name | Role | Address |
|---|---|---|
| Luna Ken | Director | P.O. Box 56192, Houston, TX, 77256 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G11000028622 | EAGLE LAKE PHARMACY | EXPIRED | 2011-03-21 | 2016-12-31 | No data | P O BOX 1467, HIGHLAND CITY, FL, 33846 |
| G11000028623 | EAGLE LAKE RX | EXPIRED | 2011-03-21 | 2016-12-31 | No data | P O BOX 1467, HIGHLAND CITY, FL, 33846 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2019-09-27 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2018-11-06 | Blanchard, Ted | No data |
| REINSTATEMENT | 2018-11-06 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2018-09-28 | No data | No data |
| AMENDMENT | 2018-04-04 | No data | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2018-03-29 | 5245 US HWY 98 N STE A, LAKELAND, FL 33809 | No data |
| AMENDMENT | 2018-03-29 | No data | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2016-04-21 | 5245 US HWY 98, STE A, LAKELAND, FL 33809 | No data |
| CHANGE OF MAILING ADDRESS | 2016-04-21 | 5245 US HWY 98, STE A, LAKELAND, FL 33809 | No data |
| Name | Date |
|---|---|
| REINSTATEMENT | 2018-11-06 |
| Amendment | 2018-04-04 |
| Amendment | 2018-03-29 |
| ANNUAL REPORT | 2017-04-28 |
| ANNUAL REPORT | 2016-04-21 |
| ANNUAL REPORT | 2015-01-20 |
| ANNUAL REPORT | 2014-04-30 |
| ANNUAL REPORT | 2013-04-29 |
| ANNUAL REPORT | 2012-01-26 |
| Domestic Profit | 2011-03-07 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
