Healthcare Provider Details

I. General information

NPI: 1639096175
Provider Name (Legal Business Name): SELAH ORA NSE ETIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 E FAIRVIEW AVE
MERIDIAN ID
83642-1821
US

IV. Provider business mailing address

1066 S SILVERSTONE WAY APT D112
MERIDIAN ID
83642-1373
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-0034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8081206
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: