=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548481021
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY JERAMY JONES PHARM D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 960 W BRIDGE ST
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4425 DEER AVE
-----------------------------------------------------
City | CHUBBUCK
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83202-2669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P5694
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------