Healthcare Provider Details

I. General information

NPI: 1912786591
Provider Name (Legal Business Name): ELIZABETH CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 BLAINE ST
CALDWELL ID
83605-4427
US

IV. Provider business mailing address

3833 E COLLINGWOOD ST # SR
MERIDIAN ID
83642-5661
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-1094
  • Fax:
Mailing address:
  • Phone: 210-501-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP10938
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: