Healthcare Provider Details

I. General information

NPI: 1215325311
Provider Name (Legal Business Name): JAMES RUSSELL WANEK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2014
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 HIGHWAY 2 SUITE A
SANDPOINT ID
83864-2711
US

IV. Provider business mailing address

1319 HIGHWAY 2 SUITE A
SANDPOINT ID
83864-2711
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-9080
  • Fax: 208-255-1695
Mailing address:
  • Phone: 208-263-9080
  • Fax: 208-255-1695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP6586
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: