1649333261 NPI number — MEDICINE MAN NORTH PHARMACY INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649333261 NPI number — MEDICINE MAN NORTH PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE MAN NORTH PHARMACY INC
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:
MEDICINE MAN NORTH 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:
1649333261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1706
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-1706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-765-2268
Provider Business Mailing Address Fax Number:
208-765-3540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 W KATHLEEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-8338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-2268
Provider Business Practice Location Address Fax Number:
208-765-3540
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KREIDER
Authorized Official First Name:
KOREY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
C00
Authorized Official Telephone Number:
206-660-3938

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 847RP , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1649333261 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2020848 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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