Provider Demographics
NPI:1023010642
Name:ST LUKE'S REG MED CTR EMPLOYEE OUTPT PHARMACY
Entity Type:Organization
Organization Name:ST LUKE'S REG MED CTR EMPLOYEE OUTPT PHARMACY
Other - Org Name:ST LUKE'S EOP
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATION MANAGER, OUTPT PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:NORMARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-381-4354
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-4353
Mailing Address - Fax:208-381-4355
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-4353
Practice Address - Fax:208-381-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1019CP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1019CPOtherPHARMACY LICENSE
1305653OtherNABP