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General NPI Number Information
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NPI Number | 1932635810
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Entity Type | Organization
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Legal Business Name | TETON PHARMACY OF ST ANTHONY
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 104 N BRIDGE ST SUITE 112
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City | SAINT ANTHONY
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State | ID
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Zip | 83445-1455
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Country | US
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Telephone | 208-624-4411
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Fax | 208-624-4412
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Provider Business Mailing Address
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Address Line | 2470 JAFER CT
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City | IDAHO FALLS
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State | ID
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Zip | 83404-5587
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Country | US
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Telephone | 208-624-4411
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Fax | 208-624-4412
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Authorized Official
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Title or Position | OWNER
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Name | JASON BAILEY
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Credential | PHARM D
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Telephone | 208-529-3636
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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 | 45043LS
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License Number State | ID
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