Healthcare Provider Details

I. General information

NPI: 1184377673
Provider Name (Legal Business Name): THOMAS SMITH PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W STATE ST
BOISE ID
83702-4039
US

IV. Provider business mailing address

19621 10TH DR SE
BOTHELL WA
98012-7765
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-7684
  • Fax:
Mailing address:
  • Phone: 425-381-7164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9854
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: