=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225252836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 287 13TH ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94612-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-832-1804
-----------------------------------------------------
Fax | 510-891-9278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 287 13TH ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94612-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-832-1804
-----------------------------------------------------
Fax | 510-891-9278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ARNOLD GEORGE FONG
-----------------------------------------------------
Credential | PHARM. D.
-----------------------------------------------------
Telephone | 510-832-1804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 27533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------