Healthcare Provider Details

I. General information

NPI: 1447710728
Provider Name (Legal Business Name): ALYSSA RENAE ZIBROWSKI PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA RENAE BUSH PHARM.D.

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 07/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 W STATE ST STE 101
EAGLE ID
83616-4911
US

IV. Provider business mailing address

477 N WHITEWATER PARK BLVD APT C107
BOISE ID
83702-5684
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-8008
  • Fax:
Mailing address:
  • Phone: 309-721-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number123392
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8236
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: