Healthcare Provider Details

I. General information

NPI: 1699696286
Provider Name (Legal Business Name): TANNER TRACY PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

6248 S ROCKROSE WAY
BOISE ID
83716-7133
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3481219
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: