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General NPI Number Information
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NPI Number | 1598229809
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Entity Type | Organization
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Legal Business Name | CLEARWATER CANYON PHARMACY, LLC
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Dates
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Enumeration Date | 01/31/2019
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Last Update Date | 04/10/2019
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Provider Practice Location Address
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Address Line | 13020 US-12
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City | OROFINO
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State | ID
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Zip | 83544
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Country | US
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Telephone | 208-476-0110
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Fax | 208-476-0115
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Provider Business Mailing Address
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Address Line | 523 THAIN RD
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City | LEWISTON
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State | ID
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Zip | 83501-5530
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Country | US
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Telephone | 208-743-5515
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Fax | 208-743-0333
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | CHARLES ANDREW POTTENGER
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Credential | PHARMD
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Telephone | 208-476-0110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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