Organization
ANGUS LAKE INFUSION SERVICES
Active
Other names
Angus Lake Vital Care
Organization subpart
No
Provider details
NPI number
Authorized official
CARL LAKE STANLEY JR. RPH (MEMBER)
(478) 387-2399
Entity
Organization
Contact information
Practice address
240 MILLEDGEVILLE RD, SUITE B, GORDON, GA 31031-3827
(478) 387-2399
(478) 628-2263
Mailing address
PO BOX 249, GORDON, GA 31031-0249
(478) 387-2399
(478) 628-2263
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
PHHH000055
GA
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
PHHH000055
GA
3336C0004X
Compounding Pharmacy
PHHH000055
GA
3336H0001X
Home Infusion Therapy Pharmacy
PHHH000055
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003137168A
—
GA
Enumeration date
04/08/2013
Last updated
10/18/2013
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