Healthcare Provider Details

I. General information

NPI: 1598681330
Provider Name (Legal Business Name): PORTER WALLENTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-6111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2881010
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: