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General NPI Number Information
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NPI Number | 1598050445
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Entity Type | Individual
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Provider Name | JESSE SUE WAGEMAN PHARMD
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Gender | Female
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Dates
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Enumeration Date | 06/17/2011
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Last Update Date | 11/10/2014
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Provider Practice Location Address
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Address Line | 4845 YELLOWSTONE AVE
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City | CHUBBUCK
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State | ID
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Zip | 83202-2333
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Country | US
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Telephone | 208-237-3900
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Fax |
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Provider Business Mailing Address
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Address Line | 1201 EAST GILBERT AVE
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City | COEUR D ALENE
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State | ID
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Zip | 83815-2333
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Country | US
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Telephone | 208-916-6879
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | E3950
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License Number State | ID
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