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NPI 1265089031 · on the registry since 2019 · sole proprietor
Practice
- Address
- 1555 Northgate Mile
Idaho Falls, ID 83401 - Phone
- (208) 535-2553
- Organisation at this address
- Fred Meyer Stores Inc
Inferred from a shared address, not stated in the registry.
- Clinicians at this address
- 6
Registry record
- Primary taxonomy
- Pharmacist
183500000X
- Licence states on file
- ID
From the registry's licence fields, which are often incomplete.
- Sex
- Male
- Record last updated
- 2019-08-26
Source: CMS National Plan and Provider Enumeration System. Registration is not the same as practising, and the registry records no retirement — some people listed here no longer practise. More in Idaho