Healthcare Provider Details

I. General information

NPI: 1174442594
Provider Name (Legal Business Name): MARISSA HARLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST
BOISE ID
83712-6223
US

IV. Provider business mailing address

3772 S CADDIS PL
BOISE ID
83716-5083
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2081411
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: