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General NPI Number Information
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NPI Number | 1205972817
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Entity Type | Organization
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Legal Business Name | FOGG DRUG CO INC
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 12/22/2014
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Provider Practice Location Address
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Address Line | 120 NORTHGATE MILE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-2543
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Country | US
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Telephone | 208-522-8357
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Fax | 208-528-0288
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Provider Business Mailing Address
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Address Line | 120 NORTHGATE MILE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-2543
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Country | US
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Telephone | 208-522-8357
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Fax | 208-528-0288
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Authorized Official
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Title or Position | MANAGER
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Name | STEPHEN FOGG
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Credential | RPH
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Telephone | 208-522-8357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 214RP
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License Number State | ID
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