Provider Demographics
NPI:1164763405
Name:LIBERTY LAKE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:LIBERTY LAKE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-891-2856
Mailing Address - Street 1:22910 E APPLEWAY AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-8606
Mailing Address - Country:US
Mailing Address - Phone:509-891-2856
Mailing Address - Fax:
Practice Address - Street 1:22910 E APPLEWAY AVE STE 3
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-8606
Practice Address - Country:US
Practice Address - Phone:509-891-2856
Practice Address - Fax:509-891-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602016543332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1952522823Medicaid
WA4084490001Medicare PIN