Healthcare Provider Details

I. General information

NPI: 1205297744
Provider Name (Legal Business Name): MICHAEL D MERRILL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S HOLMES AVE
IDAHO FALLS ID
83401-3945
US

IV. Provider business mailing address

180 S HOLMES AVE
IDAHO FALLS ID
83401-3945
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-8700
  • Fax:
Mailing address:
  • Phone: 208-525-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number703RP
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number703RP
License Number StateID

VIII. Authorized Official

Name: MICHAEL MERRILL
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 208-525-8700