Healthcare Provider Details

I. General information

NPI: 1194219634
Provider Name (Legal Business Name): JERAMY RANDALL NEIBAUR PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E COLLEGE AVE
SAINT MARIES ID
83861-2247
US

IV. Provider business mailing address

1111 S 2ND ST
SAINT MARIES ID
83861-2111
US

V. Phone/Fax

Practice location:
  • Phone: 208-245-4578
  • Fax: 208-245-5004
Mailing address:
  • Phone: 208-313-2816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberP8033
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP8033
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: