Healthcare Provider Details

I. General information

NPI: 1295161750
Provider Name (Legal Business Name): KIM MCCLUNG RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S 4TH AVE
POCATELLO ID
83201-6438
US

IV. Provider business mailing address

14516 W LACEY RD
POCATELLO ID
83202-5017
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-3341
  • Fax:
Mailing address:
  • Phone: 208-241-8785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4788
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: