Healthcare Provider Details

I. General information

NPI: 1063855211
Provider Name (Legal Business Name): ANGUS LAKE INFUSION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MILLEDGEVILLE RD SUITE B
GORDON GA
31031-3827
US

IV. Provider business mailing address

PO BOX 249
GORDON GA
31031-0249
US

V. Phone/Fax

Practice location:
  • Phone: 478-387-2399
  • Fax: 478-628-2263
Mailing address:
  • Phone: 478-387-2399
  • Fax: 478-628-2263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHHH000055
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberPHHH000055
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHHH000055
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License NumberPHHH000055
License Number StateGA

VIII. Authorized Official

Name: CARL LAKE STANLEY JR.
Title or Position: MEMBER
Credential: RPH
Phone: 478-387-2399