Healthcare Provider Details

I. General information

NPI: 1104584739
Provider Name (Legal Business Name): SANDPOINT SUPER DRUG CLINICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N FIFTH AVE
SANDPOINT ID
83864-1520
US

IV. Provider business mailing address

604 N FIFTH AVE
SANDPOINT ID
83864-1520
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1408
  • Fax:
Mailing address:
  • Phone: 208-263-1408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SCOTT PORTER
Title or Position: AUTHORIZED OFFICIAL
Credential: PHARMD
Phone: 208-263-1408