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General NPI Number Information
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NPI Number | 1700447901
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Entity Type | Individual
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Provider Name | JORDAN KELL PHARMACY INTERN
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Gender | Male
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Dates
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Enumeration Date | 06/27/2019
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Last Update Date | 06/27/2019
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Provider Practice Location Address
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Address Line | 4700 N EAGLE RD
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City | BOISE
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State | ID
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Zip | 83713-0744
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Country | US
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Telephone | 208-939-5149
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Fax | 208-939-5282
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Provider Business Mailing Address
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Address Line | 7411 E SAXTON LN
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City | NAMPA
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State | ID
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Zip | 83687-9483
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Country | US
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Telephone | 503-789-8202
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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 | I50177
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License Number State | ID
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