Healthcare Provider Details

I. General information

NPI: 1467425249
Provider Name (Legal Business Name): INTERLAKE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR SUITE 159
COEUR D ALENE ID
83814-2656
US

IV. Provider business mailing address

700 W IRONWOOD DR SUITE 159
COEUR D ALENE ID
83814-2656
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-6664
  • Fax: 208-664-8527
Mailing address:
  • Phone: 208-664-6664
  • Fax: 208-664-8527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number782CP
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number782CP
License Number StateID

VIII. Authorized Official

Name: MR. TIM BROWN
Title or Position: PHARMACIST/OWNER
Credential: RPH
Phone: 208-664-6664