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NPI Code Detail

MEDICARE: BRIAN P LAKE PHARM D

MEDICARE: BRIAN P LAKE PHARM D
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist47511TX

General Provider Information

NPI Number : 1205164225
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIAN P LAKE PHARM D
Provider Business Mailing Address
First Line : 1305 W UNIVERSITY BLVD
Second Line :
City : ODESSA
State : TX
Zip : 79764-7121
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1305 W UNIVERSITY BLVD
Second Line :
City : ODESSA
State : TX
Zip : 79764-7121
Country : US
Telephone Number : 432-580-0166
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/02/2009
Last Update Date : 12/02/2009

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Directions to “ BRIAN P LAKE PHARM D” Practice Location

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