Healthcare Provider Details

I. General information

NPI: 1326101015
Provider Name (Legal Business Name): EDITH A DVORAK PHARMD, R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 E BONNEVILLE
POCATELLO ID
83201
US

IV. Provider business mailing address

408 POLK STREET
AMERICAN FALLS ID
83211
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-3466
  • Fax:
Mailing address:
  • Phone: 208-251-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4603
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: