=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598868770
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELL LIFE PHARMACY INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 01/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 565 N VEST ST
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-7066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-773-2499
-----------------------------------------------------
Fax | 208-773-6309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1687
-----------------------------------------------------
City | BONNERS FERRY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83805-1687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-267-8929
-----------------------------------------------------
Fax | 208-267-8085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND PRESIDENT
-----------------------------------------------------
Name | JEFFREY FOSTER
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 208-267-4004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 2161RP
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------