Healthcare Provider Details

I. General information

NPI: 1578826178
Provider Name (Legal Business Name): MEDICINE MAN BONNERS FERRY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6452 MAIN ST
BONNERS FERRY ID
83805-8520
US

IV. Provider business mailing address

6452 MAIN ST
BONNERS FERRY ID
83805-8520
US

V. Phone/Fax

Practice location:
  • Phone: 208-267-4021
  • Fax: 208-267-4024
Mailing address:
  • Phone: 208-267-4021
  • Fax: 208-267-4024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number37603RP
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AIMEE STUERMER
Title or Position: CO-OWNER
Credential:
Phone: 208-627-8861