Healthcare Provider Details

I. General information

NPI: 1639805872
Provider Name (Legal Business Name): PINPAKA MCCREADY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

305 N 17TH ST APT 307
BOISE ID
83702-5152
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2121
  • Fax:
Mailing address:
  • Phone: 208-918-6926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberCT46018
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: