Provider Demographics
NPI:1598037863
Name:WEST LAKE PHARMACY INC
Entity Type:Organization
Organization Name:WEST LAKE PHARMACY INC
Other - Org Name:WEST LAKE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMLESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:732-841-5085
Mailing Address - Street 1:1828 W LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4663
Mailing Address - Country:US
Mailing Address - Phone:732-455-5885
Mailing Address - Fax:732-455-5882
Practice Address - Street 1:1828 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4663
Practice Address - Country:US
Practice Address - Phone:732-455-5885
Practice Address - Fax:732-455-5882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NJ28RS007302003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0417696Medicaid
2130488OtherPK