Healthcare Provider Details

I. General information

NPI: 1053897843
Provider Name (Legal Business Name): LETICIA JUAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2018
Last Update Date: 07/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 W OVERLAND RD
BOISE ID
83705-2633
US

IV. Provider business mailing address

9372 W HALSTEAD DR
BOISE ID
83704-6414
US

V. Phone/Fax

Practice location:
  • Phone: 208-389-1448
  • Fax:
Mailing address:
  • Phone: 208-490-2337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8066
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: