=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942590682
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY T SMITH PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2011
-----------------------------------------------------
Last Update Date | 04/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 DEINHARD LN
-----------------------------------------------------
City | MCCALL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83638-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-634-4929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 451 DEINHARD LN
-----------------------------------------------------
City | MCCALL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83638-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-634-4929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P4757
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH 35443
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------