Provider Demographics
NPI:1447611280
Name:LAKETOWN PHARMACY PLLC
Entity Type:Organization
Organization Name:LAKETOWN PHARMACY PLLC
Other - Org Name:LAKETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GOVERNOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUVALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-765-8891
Mailing Address - Street 1:1550 S PIONEER WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4637
Mailing Address - Country:US
Mailing Address - Phone:509-765-8891
Mailing Address - Fax:509-765-4280
Practice Address - Street 1:1550 S PIONEER WAY STE 105
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4637
Practice Address - Country:US
Practice Address - Phone:509-765-8891
Practice Address - Fax:509-765-4280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WA606423183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160414OtherPK
WA2070654Medicaid