Provider First Line Business Practice Location Address:
535 E 17TH ST
Provider Second Line Business Practice Location Address:
WALGREENS #05839
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-6154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-542-4569
Provider Business Practice Location Address Fax Number:
208-542-5007
Provider Enumeration Date:
10/19/2011