Provider Demographics
NPI:1316345937
Name:LAKE, ELIZABETH PAGE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:PAGE
Last Name:LAKE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FORT ROOTS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-1709
Mailing Address - Country:US
Mailing Address - Phone:501-257-3169
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:501-257-3169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-13989183500000X, 1835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02920825Medicaid