Healthcare Provider Details

I. General information

NPI: 1073079281
Provider Name (Legal Business Name): SPENCER LOUIS DIETZ PHARMD, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 E 17TH ST
AMMON ID
83406-6758
US

IV. Provider business mailing address

3270 E 17TH ST # 130
AMMON ID
83406-6758
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-7677
  • Fax:
Mailing address:
  • Phone: 208-569-5839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5827
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: