Healthcare Provider Details

I. General information

NPI: 1770580268
Provider Name (Legal Business Name): LAKE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15230 LAKESHORE DR
CLEARLAKE CA
95422
US

IV. Provider business mailing address

PO BOX 6376
CLEARLAKE CA
95422-7150
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-3141
  • Fax: 707-994-7150
Mailing address:
  • Phone: 707-994-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY55420
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TIM NGUYEN
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 925-586-2112