Healthcare Provider Details

I. General information

NPI: 1396000121
Provider Name (Legal Business Name): MELISSA ANN HERZOG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 YELLOWSTONE AVE
CHUBBUCK ID
83202-2419
US

IV. Provider business mailing address

4415 ZIEBARTH ROAD
POCATELLO ID
83204
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-6828
  • Fax:
Mailing address:
  • Phone: 208-241-6912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4850
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: