Healthcare Provider Details

I. General information

NPI: 1598742132
Provider Name (Legal Business Name): LITTLE LAKE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S MAIN ST
WILLITS CA
95490-3526
US

IV. Provider business mailing address

90 S MAIN ST
WILLITS CA
95490-3526
US

V. Phone/Fax

Practice location:
  • Phone: 707-459-6877
  • Fax: 707-459-3299
Mailing address:
  • Phone: 707-459-6877
  • Fax: 707-459-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHY34314
License Number StateCA

VIII. Authorized Official

Name: MR. DAVID H LOVITT
Title or Position: PRESIDENT
Credential: RPH
Phone: 707-459-6877