Healthcare Provider Details

I. General information

NPI: 1659700896
Provider Name (Legal Business Name): ONTARIO PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 NW 16TH ST # 150B
FRUITLAND ID
83619-2271
US

IV. Provider business mailing address

1118 NW 16TH ST # 150B
FRUITLAND ID
83619-2271
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-3340
  • Fax: 208-452-7446
Mailing address:
  • Phone: 208-452-3340
  • Fax: 208-452-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number21811LS
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ROBERT WHEATLEY
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 208-452-3340