Provider Demographics
NPI:1770580268
Name:LAKE HEALTH SERVICES
Entity type:Organization
Organization Name:LAKE HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:925-586-2112
Mailing Address - Street 1:PO BOX 6376
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-7150
Mailing Address - Country:US
Mailing Address - Phone:707-994-3141
Mailing Address - Fax:
Practice Address - Street 1:15230 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-3141
Practice Address - Fax:707-994-7150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-30
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
CAPHY554203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2001004OtherPK
CAPHA471230Medicaid