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General NPI Number Information
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NPI Number | 1578826178
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Entity Type | Organization
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Legal Business Name | MEDICINE MAN BONNERS FERRY PHARMACY LLC
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 05/23/2024
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Provider Practice Location Address
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Address Line | 6452 MAIN ST
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City | BONNERS FERRY
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State | ID
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Zip | 83805-8520
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Country | US
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Telephone | 208-267-4021
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Fax | 208-267-4024
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Provider Business Mailing Address
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Address Line | 6452 MAIN ST
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City | BONNERS FERRY
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State | ID
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Zip | 83805-8520
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Country | US
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Telephone | 208-267-4021
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Fax | 208-267-4024
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Authorized Official
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Title or Position | CO-OWNER
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Name | AIMEE STUERMER
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Credential |
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Telephone | 208-627-8861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding 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 | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 37603RP
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License Number State | ID
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