=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912292764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON KOMODA RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2011
-----------------------------------------------------
Last Update Date | 06/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16300 N MARKET PLACE BLVD
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-7910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-465-6801
-----------------------------------------------------
Fax | 208-465-6811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16300 N MARKET PLACE BLVD T-2206
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-7910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-465-6801
-----------------------------------------------------
Fax | 208-465-6811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P5939
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------