Healthcare Provider Details

I. General information

NPI: 1003571845
Provider Name (Legal Business Name): DALLIN BRENT FARNES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2021
Last Update Date: 11/06/2021
Certification Date: 10/20/2021
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: 208-934-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberP9381
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: