Provider Demographics
NPI:1477838456
Name:LAKEBRINK, TIMOTHY W (RPH)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:W
Last Name:LAKEBRINK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BOWLES AVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2338
Mailing Address - Country:US
Mailing Address - Phone:636-343-0754
Mailing Address - Fax:
Practice Address - Street 1:1001 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2338
Practice Address - Country:US
Practice Address - Phone:636-343-0754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO029401OtherPHARMACIST LICENSE NUMBER