Provider Demographics
NPI:1336323567
Name:COMPOUNDING SPECIALISTS AT LAKE OCONEE INC
Entity Type:Organization
Organization Name:COMPOUNDING SPECIALISTS AT LAKE OCONEE INC
Other - Org Name:LAKE COUNTRY PHARMACY & COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-923-2933
Mailing Address - Street 1:1110 COMMERCE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-7444
Mailing Address - Country:US
Mailing Address - Phone:706-923-2933
Mailing Address - Fax:706-923-2930
Practice Address - Street 1:1110 COMMERCE DR STE 110
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-7444
Practice Address - Country:US
Practice Address - Phone:706-923-2933
Practice Address - Fax:706-923-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
GAPHRE0099023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117665OtherPK
GA003130409AMedicaid