| Organization Name: | BALSAM LAKE PHARMACY INC |
| NPI Number: | 1427128800 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOSHUA PROHASKA (OWNER) |
| Mailing Address: | 315 Main St Balsam Lake |
| State: | WI US |
| Postal Code: | 548107262 |
| Phone Number: | 7154853374 |
| Fax Number: | 7154859074 |
| NPI Enumeration Date: | 11/09/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332B00000X |
| License Number: | 7866042 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient |