Healthcare Provider Details

I. General information

NPI: 1922405786
Provider Name (Legal Business Name): MELISSA GILLEARD PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 CLEVELAND BLVD
CALDWELL ID
83605-3852
US

IV. Provider business mailing address

1323 S MAPLE GROVE RD
BOISE ID
83709-1610
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-1792
  • Fax: 208-459-2029
Mailing address:
  • Phone: 208-319-0967
  • Fax: 208-319-0970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7162
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA-PHA-LIC-25266
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: