1093833105 NPI number — FOSTER HOLDINGS LTD

Table of content: (NPI 1093833105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093833105 NPI number — FOSTER HOLDINGS LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOSTER HOLDINGS LTD
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:
WELL LIFE SAND CREEK PHARMACY
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:
1093833105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
476864 HIGHWAY 95
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
PONDERAY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83852-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-265-0142
Provider Business Mailing Address Fax Number:
208-265-0185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476864 HWY 95 N
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-9737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-0142
Provider Business Practice Location Address Fax Number:
208-265-0185
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-290-5362

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  2152CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2152CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: 2152CP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 807709100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1307760 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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