Healthcare Provider Details

I. General information

NPI: 1508375924
Provider Name (Legal Business Name): LACEY VALE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 E BOISE AVE
BOISE ID
83706-5118
US

IV. Provider business mailing address

5986 S WALLFLOWER PL
BOISE ID
83716-7014
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-8340
  • Fax:
Mailing address:
  • Phone: 208-720-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7863
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: