Healthcare Provider Details

I. General information

NPI: 1285262808
Provider Name (Legal Business Name): MAURIA PRINCE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 3RD AVE
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

PO BOX 705
PONDERAY ID
83852-0705
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-3731
  • Fax: 208-265-1031
Mailing address:
  • Phone: 208-304-1813
  • Fax: 208-265-1031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP4371
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: