Healthcare Provider Details

I. General information

NPI: 1275088767
Provider Name (Legal Business Name): SHELBY LANCASTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 MAIN ST
GOODING ID
83330-1315
US

IV. Provider business mailing address

414 MAIN ST
GOODING ID
83330-1315
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-4000
  • Fax:
Mailing address:
  • Phone: 208-934-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7516
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: