1821159997 NPI number — MEDICINE MAN NORTH PHARMACY INC

Table of content: (NPI 1821159997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821159997 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:
Provider Other Organization Name Type Code:
6
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:
1821159997
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:
208-772-3311
Provider Business Mailing Address Fax Number:
208-772-1779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 W HAYDEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835-8194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-772-3311
Provider Business Practice Location Address Fax Number:
208-772-1779
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KREIDER
Authorized Official First Name:
KOREY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
208-660-3938

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: 864RP , 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: 1821159997 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2020947 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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