Healthcare Provider Details

I. General information

NPI: 1164850160
Provider Name (Legal Business Name): ROBERT NEWSOM RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4257 YELLOWSTONE AVE
CHUBBUCK ID
83202-2419
US

IV. Provider business mailing address

4257 YELLOWSTONE AVE
CHUBBUCK ID
83202-2419
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-3940
  • Fax:
Mailing address:
  • Phone: 208-237-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4868
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number39022
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8868
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: