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General NPI Number Information
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NPI Number | 1861806820
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Entity Type | Organization
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Legal Business Name | BEAR LAKE DRUG LLC
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 01/18/2017
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Provider Practice Location Address
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Address Line | 836 WASHINGTON ST
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City | MONTPELIER
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State | ID
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Zip | 83254-1423
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Country | US
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Telephone | 208-847-1421
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Fax | 208-847-1690
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Provider Business Mailing Address
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Address Line | 836 WASHINGTON ST
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City | MONTPELIER
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State | ID
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Zip | 83254-1423
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Country | US
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Telephone | 208-847-1421
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Fax | 208-847-1690
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Authorized Official
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Title or Position | PHARMD
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Name | CASEY HUMPHERYS
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Credential |
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Telephone | 208-847-1421
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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 | 1440RP
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License Number State | ID
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