Provider Demographics
NPI:1669021127
Name:LAKE, GARRY PATRICK (RPH)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:PATRICK
Last Name:LAKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3440 S BRYANT BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-9308
Mailing Address - Country:US
Mailing Address - Phone:325-276-6598
Mailing Address - Fax:325-276-6597
Practice Address - Street 1:3440 S BRYANT BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-9308
Practice Address - Country:US
Practice Address - Phone:325-276-6598
Practice Address - Fax:325-276-6597
Is Sole Proprietor?:No
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist