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General NPI Number Information
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NPI Number | 1942747472
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Entity Type | Organization
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Legal Business Name | TETON PHARMACY OF RIGBY LLC
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Dates
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Enumeration Date | 01/23/2017
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Last Update Date | 03/06/2017
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Provider Practice Location Address
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Address Line | 527 RIGBY LAKE DR STE C
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City | RIGBY
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State | ID
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Zip | 83442-5117
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Country | US
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Telephone | 208-745-9450
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Fax | 208-745-9465
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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 | 208-529-3636
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Fax |
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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 |
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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 | 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 | 44146RP
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License Number State | ID
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