Basic Information
| Provider Information | |||||||||
| NPI: | 1386018406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3717 E MORNING STAR LN | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852984822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806345906 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 W FRYE RD | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852244950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886947287 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2015 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S014383 | AZ | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 0202011748 | VA | N | Pharmacy Service Providers | Pharmacist |
No ID Information.