Healthcare Provider Details

I. General information

NPI: 1588896245
Provider Name (Legal Business Name): NORTHLAKE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7047 HIGHWAY 190 EAST SERVICE RD EAST SERVICE ROAD
COVINGTON LA
70433-4955
US

IV. Provider business mailing address

7047 HIGHWAY 190 EAST SERVICE RD EAST SERVICE ROAD
COVINGTON LA
70433-4955
US

V. Phone/Fax

Practice location:
  • Phone: 985-327-0594
  • Fax: 985-327-0597
Mailing address:
  • Phone: 985-327-0594
  • Fax: 985-327-0597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY006184IR
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CHAMBERLAIN
Title or Position: PRESIDENT/P.I.C.
Credential:
Phone: 985-327-0594