Healthcare Provider Details

I. General information

NPI: 1972633915
Provider Name (Legal Business Name): MAAG PRESCRIPTION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W. CENTER ST.
POCATELLO ID
83204
US

IV. Provider business mailing address

PO BOX 115
POCATELLO ID
83204-0115
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2063
  • Fax: 208-233-6158
Mailing address:
  • Phone: 208-233-2063
  • Fax: 208-233-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number526CP
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number526CP
License Number StateID

VIII. Authorized Official

Name: KATHLEEN CAROL MAAG
Title or Position: CFO/OWNER
Credential:
Phone: 208-233-2063