Healthcare Provider Details

I. General information

NPI: 1780804435
Provider Name (Legal Business Name): C. DUSTIN WATERS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

10042 W GARVERDALE DR APT 102
BOISE ID
83704-8026
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberP6019
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: