Healthcare Provider Details

I. General information

NPI: 1023010642
Provider Name (Legal Business Name): ST LUKE'S REG MED CTR EMPLOYEE OUTPT PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-4353
  • Fax: 208-381-4355
Mailing address:
  • Phone: 208-381-4353
  • Fax: 208-381-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1019CP
License Number StateID

VIII. Authorized Official

Name: JAMES W NORMARK
Title or Position: OPERATION MANAGER, OUTPT PHARMACY
Credential: RPH
Phone: 208-381-4354