Healthcare Provider Details

I. General information

NPI: 1417874066
Provider Name (Legal Business Name): DALLISA JOHNSON CPHT-ADV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3046
US

IV. Provider business mailing address

517 ELM ST # 194
TROY ID
83871-0077
US

V. Phone/Fax

Practice location:
  • Phone: 208-883-6245
  • Fax:
Mailing address:
  • Phone: 208-596-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberCT1222
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: