Healthcare Provider Details

I. General information

NPI: 1265515357
Provider Name (Legal Business Name): LOST RIVERS HOSPITAL PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 HIGHLAND DR
ARCO ID
83213
US

IV. Provider business mailing address

PO BOX 145
ARCO ID
83213-0145
US

V. Phone/Fax

Practice location:
  • Phone: 208-527-8206
  • Fax: 208-527-3105
Mailing address:
  • Phone: 208-527-8206
  • Fax: 208-527-3105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5347
License Number StateID

VIII. Authorized Official

Name: BRAD HUERTA
Title or Position: CEO
Credential:
Phone: 208-527-8206