Healthcare Provider Details

I. General information

NPI: 1659907962
Provider Name (Legal Business Name): MEDICINE MAN COMPOUNDING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 N VEST ST
POST FALLS ID
83854-7066
US

IV. Provider business mailing address

565 N VEST ST
POST FALLS ID
83854-7066
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DONALD RAY SMITH
Title or Position: MANAGING PARNER
Credential: RPH
Phone: 208-661-5199