Healthcare Provider Details

I. General information

NPI: 1548423338
Provider Name (Legal Business Name): HEARTLAND PHARMACY - IDAHO FALLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 E 17TH ST
AMMON ID
83406-6758
US

IV. Provider business mailing address

1790 SABIN DR
AMMON ID
83406-6747
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-7677
  • Fax: 208-552-2103
Mailing address:
  • Phone: 208-497-3575
  • Fax: 208-552-2103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1624LS
License Number StateID

VIII. Authorized Official

Name: REECE CHRISTENSEN
Title or Position: CEO PRESIDENT
Credential:
Phone: 208-497-3575