Healthcare Provider Details

I. General information

NPI: 1558288027
Provider Name (Legal Business Name): RULON EPHRAIM SQUIRE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

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

4921 S 5TH AVE
POCATELLO ID
83204-2209
US

IV. Provider business mailing address

1550 EASTPOINTE DR
POCATELLO ID
83201-5159
US

V. Phone/Fax

Practice location:
  • Phone: 623-606-7930
  • Fax:
Mailing address:
  • Phone: 623-606-7930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP10841
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1835N0905X
TaxonomyNuclear Pharmacist
License Number24939
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code1835N0905X
TaxonomyNuclear Pharmacist
License NumberP10841
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: