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General NPI Number Information
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NPI Number | 1669460093
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Entity Type | Organization
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Legal Business Name | VIC'S FAMILY PHARMACY INC
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Dates
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Enumeration Date | 10/10/2005
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Last Update Date | 10/29/2009
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Provider Practice Location Address
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Address Line | 173 E 4TH ST
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City | KUNA
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State | ID
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Zip | 83634-2103
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Country | US
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Telephone | 208-922-4400
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Fax | 208-922-4499
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Provider Business Mailing Address
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Address Line | 119 S VALLEY DR STE A
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City | NAMPA
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State | ID
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Zip | 83686-2985
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Country | US
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Telephone | 208-922-4400
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Fax | 208-922-4499
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Authorized Official
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Title or Position | PHARMACIST IN CHARGE
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Name | MR. TRAVIS L WALTHALL
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Credential | RPH
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Telephone | 208-922-4400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 1271CP
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License Number State | ID
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