1013791797 NPI number — ST LUKE'S REGIONAL MEDICAL CENTER

Table of content: (NPI 1013791797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013791797 NPI number — ST LUKE'S REGIONAL MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LUKE'S REGIONAL MEDICAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST LUKES RETAIL PHARMACY FRUITLAND
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013791797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 640
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83701-0640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-205-7779
Provider Business Mailing Address Fax Number:
208-205-7778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1118 NW 16TH ST STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-9890
Provider Business Practice Location Address Fax Number:
208-452-9899
Provider Enumeration Date:
08/23/2023

Additional Information

Authorized Official

Authorized Official Last Name:
CURTIS
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF PHARMACY OFFICER
Authorized Official Telephone Number:
208-493-2307

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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