Healthcare Provider Details

I. General information

NPI: 1063187029
Provider Name (Legal Business Name): KAITLIN ANN ROURK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

2841 S TAGGART LN
BOISE ID
83705-4146
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2490
  • Fax:
Mailing address:
  • Phone: 208-982-0169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9530
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: