Healthcare Provider Details

I. General information

NPI: 1285542191
Provider Name (Legal Business Name): COLLIN CROOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 YELLOWSTONE AVE
CHUBBUCK ID
83202-2333
US

IV. Provider business mailing address

4845 YELLOWSTONE AVE
CHUBBUCK ID
83202-2333
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-3900
  • Fax:
Mailing address:
  • Phone: 208-237-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberI71716
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: