Provider Demographics
NPI:1043629397
Name:TETON CLINICAL PHARMACY, INC.
Entity Type:Organization
Organization Name:TETON CLINICAL PHARMACY, INC.
Other - Org Name:TETON PHARMACY ON BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-360-1317
Mailing Address - Street 1:1855 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3043
Mailing Address - Country:US
Mailing Address - Phone:208-529-3638
Mailing Address - Fax:208-529-1715
Practice Address - Street 1:1855 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3043
Practice Address - Country:US
Practice Address - Phone:208-529-3638
Practice Address - Fax:208-529-1715
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON CLINICAL PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-11
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy