Healthcare Provider Details

I. General information

NPI: 1598784217
Provider Name (Legal Business Name): ROD THAD TUCKER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 TYHEE AVE
AMERICAN FALLS ID
83211-1224
US

IV. Provider business mailing address

3136 WILLOW ST
AMERICAN FALLS ID
83211-5520
US

V. Phone/Fax

Practice location:
  • Phone: 208-226-2411
  • Fax: 208-226-5124
Mailing address:
  • Phone: 208-226-2411
  • Fax: 208-226-5124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4009
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: