1770807935 NPI number — BENJAMIN LAKE STANLEY PHARM D.

Table of content: BENJAMIN LAKE STANLEY PHARM D. (NPI 1770807935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770807935 NPI number — BENJAMIN LAKE STANLEY PHARM D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANLEY
Provider First Name:
BENJAMIN
Provider Middle Name:
LAKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770807935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 MILLEDGEVILLE HWY
Provider Second Line Business Mailing Address:
P.O. BOX 249
Provider Business Mailing Address City Name:
GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31031-3827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-628-2481
Provider Business Mailing Address Fax Number:
478-628-2263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 MILLEDGEVILLE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31031-3827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-628-2481
Provider Business Practice Location Address Fax Number:
478-628-2263
Provider Enumeration Date:
03/17/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  025078 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: 20457 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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