Healthcare Provider Details

I. General information

NPI: 1275245615
Provider Name (Legal Business Name): PRESTON DRUG HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 N 1ST E
PRESTON ID
83263-1325
US

IV. Provider business mailing address

39 N 1ST E
PRESTON ID
83263-1325
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-1563
  • Fax: 208-852-1268
Mailing address:
  • Phone: 208-852-1563
  • Fax: 208-852-1268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SETH HASLAM
Title or Position: OWNER
Credential: PHARMD
Phone: 208-851-1561