Healthcare Provider Details

I. General information

NPI: 1265425433
Provider Name (Legal Business Name): DEAN A WALLENTINE PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 WASHINGTON ST
MONTPELIER ID
83254-1423
US

IV. Provider business mailing address

836 WASHINGTON ST
MONTPELIER ID
83254-1423
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-1421
  • Fax: 208-847-1690
Mailing address:
  • Phone: 208-847-1421
  • Fax: 208-847-1690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5441
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberP5441
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1440CP
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: