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General NPI Number Information
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NPI Number | 1467425249
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Entity Type | Organization
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Legal Business Name | INTERLAKE PHARMACY INC
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Dates
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Enumeration Date | 02/10/2006
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Last Update Date | 09/14/2015
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Provider Practice Location Address
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Address Line | 700 W IRONWOOD DR SUITE 159
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2656
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Country | US
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Telephone | 208-664-6664
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Fax | 208-664-8527
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Provider Business Mailing Address
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Address Line | 700 W IRONWOOD DR SUITE 159
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2656
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Country | US
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Telephone | 208-664-6664
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Fax | 208-664-8527
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Authorized Official
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Title or Position | PHARMACIST/OWNER
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Name | MR. TIM BROWN
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Credential | RPH
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Telephone | 208-664-6664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 782CP
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 782CP
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License Number State | ID
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