Healthcare Provider Details

I. General information

NPI: 1891885844
Provider Name (Legal Business Name): OSBURN DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 MULLAN AVE.
OSBURN ID
83849
US

IV. Provider business mailing address

P.O. BOX 2170
OSBURN ID
83849
US

V. Phone/Fax

Practice location:
  • Phone: 208-556-1139
  • Fax: 208-556-7311
Mailing address:
  • Phone: 208-556-1139
  • Fax: 208-556-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberCP245
License Number StateID

VIII. Authorized Official

Name: MR. RONALD DALE LAVIGNE
Title or Position: PRESIDENT
Credential: R.PH
Phone: 208-556-1139