Provider Demographics
NPI:1588896245
Name:NORTHLAKE PHARMACY INC
Entity type:Organization
Organization Name:NORTHLAKE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/P.I.C.
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-327-0594
Mailing Address - Street 1:7047 HIGHWAY 190 EAST SERVICE RD
Mailing Address - Street 2:EAST SERVICE ROAD
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4955
Mailing Address - Country:US
Mailing Address - Phone:985-327-0594
Mailing Address - Fax:985-327-0597
Practice Address - Street 1:7047 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:EAST SERVICE ROAD
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4955
Practice Address - Country:US
Practice Address - Phone:985-327-0594
Practice Address - Fax:985-327-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
LAPHY006184IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1934682OtherNCPDP PROVIDER IDENTIFICATION NUMBER