Healthcare Provider Details

I. General information

NPI: 1861806820
Provider Name (Legal Business Name): BEAR LAKE DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 01/18/2017
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1440RP
License Number StateID

VIII. Authorized Official

Name: CASEY HUMPHERYS
Title or Position: PHARMD
Credential:
Phone: 208-847-1421