Healthcare Provider Details

I. General information

NPI: 1790440469
Provider Name (Legal Business Name): DARYLL BUTLER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2021
Last Update Date: 11/07/2021
Certification Date: 11/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 W PRAIRIE SHOPPING CTR
HAYDEN ID
83835-9854
US

IV. Provider business mailing address

3153 N GUINNESS LN APT 202
POST FALLS ID
83854-0072
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-2774
  • Fax:
Mailing address:
  • Phone: 307-315-4058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP9787
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: