Healthcare Provider Details

I. General information

NPI: 1255269759
Provider Name (Legal Business Name): JANE LEE PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

IV. Provider business mailing address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3281210
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: