Provider Demographics
NPI:1730724105
Name:SILVER LAKE PHARMACY INC
Entity type:Organization
Organization Name:SILVER LAKE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDERSON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:877-425-6667
Mailing Address - Street 1:1412 SW 43RD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4803
Mailing Address - Country:US
Mailing Address - Phone:877-425-6337
Mailing Address - Fax:877-509-6337
Practice Address - Street 1:10315 19TH AVE SE STE 104
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4268
Practice Address - Country:US
Practice Address - Phone:877-425-6337
Practice Address - Fax:877-509-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-09
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy