Provider Demographics
NPI:1578667689
Name:ICON PHARMACEUTICALS INC
Entity Type:Organization
Organization Name:ICON PHARMACEUTICALS INC
Other - Org Name:ICON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOC EXEC
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LABREQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-872-7088
Mailing Address - Street 1:300 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3544
Mailing Address - Country:US
Mailing Address - Phone:407-649-8050
Mailing Address - Fax:407-649-8051
Practice Address - Street 1:300 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3544
Practice Address - Country:US
Practice Address - Phone:407-649-8050
Practice Address - Fax:407-649-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
FLPH215543336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005354OtherPK