Healthcare Provider Details

I. General information

NPI: 1609800937
Provider Name (Legal Business Name): EASTGATE DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/11/2025
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

3250 E 17TH ST
AMMON ID
83406-6758
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-1243
  • Fax: 208-523-3780
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1010CP
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: COREY SMITH
Title or Position: PRESIDENT
Credential:
Phone: 208-522-1243