Healthcare Provider Details

I. General information

NPI: 1588205959
Provider Name (Legal Business Name): JACOB CROSSLEY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W STATE ST
BOISE ID
83702-4039
US

IV. Provider business mailing address

13186 S CATAWBA RIVER AVE
NAMPA ID
83686-6836
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-7684
  • Fax:
Mailing address:
  • Phone: 208-252-1071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8400
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: