=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467891697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA KATHLEEN ALLGOOD B.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2013
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 N HIGHBROOK WAY
-----------------------------------------------------
City | STAR
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83669-6219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-272-9450
-----------------------------------------------------
Fax | 208-272-9449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3023 S CREEK POINTE LN
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-7186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-736-3490
-----------------------------------------------------
Fax | 208-272-9449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.288300
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P8284
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------