Healthcare Provider Details

I. General information

NPI: 1508157603
Provider Name (Legal Business Name): ALLISON CLARK DEYETTE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16700 N MARKET PLACE BLVD
NAMPA ID
83687-7909
US

IV. Provider business mailing address

16700 N MARKET PLACE BLVD
NAMPA ID
83687-7909
US

V. Phone/Fax

Practice location:
  • Phone: 208-465-3809
  • Fax: 208-465-3806
Mailing address:
  • Phone: 208-465-3809
  • Fax: 208-465-3806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5582
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: