=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952685273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY DUANE CALKINS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2011
-----------------------------------------------------
Last Update Date | 10/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8100 W FAIRVIEW AVE
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-375-2825
-----------------------------------------------------
Fax | 208-375-2846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16685 ROSE BRIAR LN
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-8446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-465-4283
-----------------------------------------------------
Fax | 208-463-4283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | P3988
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------