Provider First Line Business Practice Location Address:
SAFEWAY #2954
Provider Second Line Business Practice Location Address:
6519 MAIN ST
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-2301
Provider Business Practice Location Address Fax Number:
208-267-5942
Provider Enumeration Date:
09/09/2011