Provider Demographics
NPI:1730101353
Name:STANLEY, CARL LAKE JR (RPH, CDM)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:LAKE
Last Name:STANLEY
Suffix:JR
Gender:M
Credentials:RPH, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
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
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist