Healthcare Provider Details

I. General information

NPI: 1013961739
Provider Name (Legal Business Name): GREGORY FOREST CRAVENS R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

1836 SE 3RD WAY
MERIDIAN ID
83642-6652
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1071
  • Fax: 208-422-1082
Mailing address:
  • Phone: 208-422-1071
  • Fax: 208-422-1082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberP4745
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: