Organization
ANGUS LAKE INFUSION SERVICES
Active
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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