Healthcare Provider Details

I. General information

NPI: 1356980775
Provider Name (Legal Business Name): KRISTEN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

730 E HIGHLAND VIEW DR
BOISE ID
83702-1919
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2490
  • Fax:
Mailing address:
  • Phone: 801-550-6639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0200X
TaxonomyPediatric Pharmacist
License NumberP7098
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: