Healthcare Provider Details

I. General information

NPI: 1831561034
Provider Name (Legal Business Name): TETON PHARMACY IN AMMON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 E 17TH ST STE 164
AMMON ID
83406-6784
US

IV. Provider business mailing address

2470 JAFER CT
IDAHO FALLS ID
83404-5587
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-1795
  • Fax: 208-529-1838
Mailing address:
  • Phone: 208-529-3636
  • Fax: 208-529-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PHILIP HARPER
Title or Position: OWNER
Credential: DMD
Phone: 208-529-3638