Provider Demographics
NPI:1013540814
Name:SALMON PHARMACY, LLC
Entity Type:Organization
Organization Name:SALMON PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-742-3784
Mailing Address - Street 1:309 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467
Mailing Address - Country:US
Mailing Address - Phone:208-742-3784
Mailing Address - Fax:208-742-6363
Practice Address - Street 1:309 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467
Practice Address - Country:US
Practice Address - Phone:208-742-3784
Practice Address - Fax:208-742-6363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-20
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1013540814Medicaid