Provider Demographics
NPI:1487789400
Name:LAKE VILLAGE DRUGSTORE, INC.
Entity type:Organization
Organization Name:LAKE VILLAGE DRUGSTORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER/PHARMACIST IN CHAR
Authorized Official - Prefix:
Authorized Official - First Name:KAMILA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:870-265-5555
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-0548
Mailing Address - Country:US
Mailing Address - Phone:870-265-5555
Mailing Address - Fax:
Practice Address - Street 1:2907 HWY 65-82 SOUTH
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653
Practice Address - Country:US
Practice Address - Phone:870-265-5555
Practice Address - Fax:870-265-3174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0403890183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100517407Medicaid