Healthcare Provider Details

I. General information

NPI: 1023411139
Provider Name (Legal Business Name): SETH WILLIAM HASLAM PHARMD.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 NORTH 1ST EAST
PRESTON ID
83263-1644
US

IV. Provider business mailing address

39 NORTH 1ST EAST
PRESTON ID
83263-1644
US

V. Phone/Fax

Practice location:
  • Phone: 208-851-1561
  • Fax: 208-852-1268
Mailing address:
  • Phone: 208-851-1561
  • Fax: 208-852-1268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP6707
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: