Healthcare Provider Details

I. General information

NPI: 1598868770
Provider Name (Legal Business Name): WELL LIFE PHARMACY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 N VEST ST
POST FALLS ID
83854-7066
US

IV. Provider business mailing address

PO BOX 1687
BONNERS FERRY ID
83805-1687
US

V. Phone/Fax

Practice location:
  • Phone: 208-773-2499
  • Fax: 208-773-6309
Mailing address:
  • Phone: 208-267-8929
  • Fax: 208-267-8085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2161RP
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY FOSTER
Title or Position: OWNER AND PRESIDENT
Credential: RPH
Phone: 208-267-4004