MEDICARE: MEDICINE MAN WEST LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	1114RP	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2021075	OTHER		PK

General Provider Information

NPI Number	:	1982778403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICINE MAN WEST LLC

Provider Business Mailing Address
First Line	:	805 E POLSTON AVE
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83854-6044
Country	:	US
Telephone Number	:	208-777-7732
Fax Number	:	208-777-0201

Provider Business Practice Location Address
First Line	:	805 E POLSTON AVE
Second Line	:
City	:	POST FALLS
State	:	ID
Zip	:	83854-6044
Country	:	US
Telephone Number	:	208-777-7732
Fax Number	:	208-777-0201

Authorized Official
Title or Position	:	OWNER
Name	:	DONALD SMITH
Credential	:
Telephone Number	:	208-777-7732

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	09/14/2016

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Directions to “MEDICINE MAN WEST LLC ” Practice Location

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