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General NPI Number Information
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NPI Number | 1821159997
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Entity Type | Organization
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Legal Business Name | MEDICINE MAN NORTH PHARMACY INC
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 06/03/2022
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Provider Practice Location Address
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Address Line | 240 W HAYDEN AVE
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City | HAYDEN
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State | ID
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Zip | 83835-8194
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Country | US
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Telephone | 208-772-3311
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Fax | 208-772-1779
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Provider Business Mailing Address
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Address Line | PO BOX 1706
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City | HAYDEN
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State | ID
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Zip | 83835-1706
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Country | US
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Telephone | 208-772-3311
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Fax | 208-772-1779
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Authorized Official
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Title or Position | COO
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Name | KOREY E KREIDER
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Credential | PHARMD
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Telephone | 208-660-3938
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 864RP
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License Number State | ID
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