Healthcare Provider Details

I. General information

NPI: 1962581652
Provider Name (Legal Business Name): MEDICAL CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E ELM ST SUITE150
CALDWELL ID
83605-4857
US

IV. Provider business mailing address

315 E ELM ST SUITE150
CALDWELL ID
83605-4857
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-1503
  • Fax: 208-459-1504
Mailing address:
  • Phone: 208-459-1503
  • Fax: 208-459-1504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2373RP
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TYLER HIGGINS
Title or Position: PRESIDENT
Credential:
Phone: 208-459-1503