Healthcare Provider Details

I. General information

NPI: 1063145993
Provider Name (Legal Business Name): MEGAN LEE LAKE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 FLAMMANG DR
WATERLOO IA
50702-4368
US

IV. Provider business mailing address

135 HARVEY DR
WATERLOO IA
50701-2313
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-1774
  • Fax:
Mailing address:
  • Phone: 712-301-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24471
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: