Healthcare Provider Details

I. General information

NPI: 1669460093
Provider Name (Legal Business Name): VIC'S FAMILY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 E 4TH ST
KUNA ID
83634-2103
US

IV. Provider business mailing address

119 S VALLEY DR STE A
NAMPA ID
83686-2985
US

V. Phone/Fax

Practice location:
  • Phone: 208-922-4400
  • Fax: 208-922-4499
Mailing address:
  • Phone: 208-922-4400
  • Fax: 208-922-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1271CP
License Number StateID

VIII. Authorized Official

Name: MR. TRAVIS L WALTHALL
Title or Position: PHARMACIST IN CHARGE
Credential: RPH
Phone: 208-922-4400