Healthcare Provider Details

I. General information

NPI: 1710056445
Provider Name (Legal Business Name): HEARTLAND PHARMACY - BOISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8455 W EMERALD ST
BOISE ID
83704-8306
US

IV. Provider business mailing address

1790 SABIN DR
AMMON ID
83406-6747
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-0067
  • Fax: 208-323-5954
Mailing address:
  • Phone: 208-497-3575
  • Fax: 208-552-2103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number1679LS
License Number StateID

VIII. Authorized Official

Name: ANDREA FERGUSON
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 208-497-3575