Healthcare Provider Details

I. General information

NPI: 1396802773
Provider Name (Legal Business Name): TETON CLINICAL PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 JAFER CT.
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

2470 JAFER CT.
IDAHO FALLS ID
83404
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-3636
  • Fax: 208-529-1715
Mailing address:
  • Phone: 208-529-3636
  • Fax: 208-529-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number2226CP
License Number StateID

VIII. Authorized Official

Name: MS. PAMELA ANN BAILEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-529-3636