Healthcare Provider Details

I. General information

NPI: 1699814574
Provider Name (Legal Business Name): BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

IV. Provider business mailing address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-1630
  • Fax: 208-847-4475
Mailing address:
  • Phone: 208-847-1630
  • Fax: 208-847-4475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number555HP
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberHP555
License Number StateID

VIII. Authorized Official

Name: MRS. LYNETTE DAWN WILLIAMS
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 208-847-1630