Provider Demographics
NPI:1275637787
Name:ANGUS LAKE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:ANGUS LAKE HEALTHCARE, LLC
Other - Org Name:GORDON COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAPPE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:478-628-2425
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:240A MILLEDGEVILLE ROAD
Mailing Address - City:GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:31031-0249
Mailing Address - Country:US
Mailing Address - Phone:478-628-2425
Mailing Address - Fax:478-628-2263
Practice Address - Street 1:240 MILLEDGEVILLE HWY # A
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:GA
Practice Address - Zip Code:31031-3827
Practice Address - Country:US
Practice Address - Phone:478-628-2425
Practice Address - Fax:478-628-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0089123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy