=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386820314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRWIN DRUG INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2008
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 W MAIN ST
-----------------------------------------------------
City | GRANGEVILLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83530-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-983-1090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 W MAIN ST
-----------------------------------------------------
City | GRANGEVILLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83530-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-983-1090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MR. CHAD GUY JUNGERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-983-1090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 2081CP
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------