Provider Demographics
NPI:1003196569
Name:LAKE, LANCE (RPH)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
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 1:1675 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-5152
Mailing Address - Country:US
Mailing Address - Phone:417-485-0762
Mailing Address - Fax:417-485-0793
Practice Address - Street 1:1675 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-5152
Practice Address - Country:US
Practice Address - Phone:417-485-0762
Practice Address - Fax:417-485-0793
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010937183500000X
SD4847183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist