Healthcare Provider Details

I. General information

NPI: 1245840065
Provider Name (Legal Business Name): COLTON JOHN PLOUZEK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 W CHINDEN BLVD
MERIDIAN ID
83646-7151
US

IV. Provider business mailing address

4848 W BEECHSTONE ST
MERIDIAN ID
83646-4917
US

V. Phone/Fax

Practice location:
  • Phone: 986-200-4146
  • Fax: 986-200-4137
Mailing address:
  • Phone: 385-350-7563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9001
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7788409-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: