Healthcare Provider Details

I. General information

NPI: 1366630436
Provider Name (Legal Business Name): RITE AID
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2007
Last Update Date: 10/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W BROADWAY ST
IDAHO FALLS ID
83402-3045
US

IV. Provider business mailing address

1745 W BROADWAY ST
IDAHO FALLS ID
83402-3045
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-4480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP6096
License Number StateID

VIII. Authorized Official

Name: JOHN RYAN BRONSELL
Title or Position: STAFF PHARMACIST
Credential: PHARMD
Phone: 208-524-4480