MEDICARE: ALLEN PHARMACY SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	322B00000X	ID

General Provider Information

NPI Number	:	1174607337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEN PHARMACY SERVICE

Provider Business Mailing Address
First Line	:	23 N BRIDGE ST
Second Line	:
City	:	SAINT ANTHONY
State	:	ID
Zip	:	83445-2110
Country	:	US
Telephone Number	:	208-624-3202
Fax Number	:	208-624-3760

Provider Business Practice Location Address
First Line	:	23 N BRIDGE ST
Second Line	:
City	:	SAINT ANTHONY
State	:	ID
Zip	:	83445-2110
Country	:	US
Telephone Number	:	208-624-3202
Fax Number	:	208-624-3760

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAUL A ALLEN
Credential	:
Telephone Number	:	208-624-3202

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	08/22/2020

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