Healthcare Provider Details

I. General information

NPI: 1093355224
Provider Name (Legal Business Name): CHARLES PAINTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

IV. Provider business mailing address

8633 W FALLING STAR ST
BOISE ID
83709-6368
US

V. Phone/Fax

Practice location:
  • Phone: 208-395-5561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberCT61906
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPHAT.0019006
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number166837
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: