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General NPI Number Information
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NPI Number | 1982778403
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Entity Type | Organization
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Legal Business Name | MEDICINE MAN WEST LLC
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 09/14/2016
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Provider Practice Location Address
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Address Line | 805 E POLSTON AVE
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City | POST FALLS
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State | ID
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Zip | 83854-6044
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Country | US
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Telephone | 208-777-7732
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Fax | 208-777-0201
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Provider Business Mailing Address
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Address Line | 805 E POLSTON AVE
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City | POST FALLS
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State | ID
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Zip | 83854-6044
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Country | US
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Telephone | 208-777-7732
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Fax | 208-777-0201
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Authorized Official
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Title or Position | OWNER
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Name | DONALD SMITH
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Credential |
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Telephone | 208-777-7732
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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 | 1114RP
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License Number State | ID
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