Provider Demographics
NPI:1467425249
Name:INTERLAKE PHARMACY INC
Entity Type:Organization
Organization Name:INTERLAKE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-664-6664
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 159
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-664-6664
Mailing Address - Fax:208-664-8527
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 159
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-664-6664
Practice Address - Fax:208-664-8527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID782CP183500000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002627900Medicaid
ID001679200Medicaid
ID002627900Medicaid