Healthcare Provider Details

I. General information

NPI: 1740717693
Provider Name (Legal Business Name): SNAKE RIVER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 YELLOWSTONE AVE
CHUBBUCK ID
83202-2336
US

IV. Provider business mailing address

4750 YELLOWSTONE AVE
CHUBBUCK ID
83202-2336
US

V. Phone/Fax

Practice location:
  • Phone: 208-240-3733
  • Fax:
Mailing address:
  • Phone: 208-240-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number44698RP
License Number StateID

VIII. Authorized Official

Name: DR. BRIAN LUNT
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 208-240-3733