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General NPI Number Information
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NPI Number | 1679082945
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Entity Type | Organization
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Legal Business Name | LADD FAMILY PHARMACY LLC
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Dates
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Enumeration Date | 09/29/2017
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Last Update Date | 09/29/2017
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Provider Practice Location Address
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Address Line | 2000 AMERICAN LEGION BLVD
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-3138
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Country | US
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Telephone | 208-947-0877
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Fax | 208-947-0874
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Provider Business Mailing Address
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Address Line | 1109 S BROADWAY AVE
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City | BOISE
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State | ID
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Zip | 83706-3626
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Country | US
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Telephone | 208-947-0877
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Fax |
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Authorized Official
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Title or Position | C.O.O
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Name | JEREMY LUNDEVALL
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Credential |
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Telephone | 208-947-0877
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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 | 46393LS
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License Number State | ID
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