Provider Demographics
NPI:1811715402
Name:LAKE, CODIE ALLEN (PHARMD)
Entity type:Individual
Prefix:
First Name:CODIE
Middle Name:ALLEN
Last Name:LAKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7468 KY 1304
Mailing Address - Street 2:
Mailing Address - City:GIRDLER
Mailing Address - State:KY
Mailing Address - Zip Code:40943-6406
Mailing Address - Country:US
Mailing Address - Phone:606-622-9923
Mailing Address - Fax:
Practice Address - Street 1:301 PARKWAY PLZ
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-7429
Practice Address - Country:US
Practice Address - Phone:606-546-5477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY024622183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist