Provider Demographics
NPI:1053860767
Name:GOODING PHARMACY INC
Entity Type:Organization
Organization Name:GOODING PHARMACY INC
Other - Org Name:SHOSHONE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:READING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-3784
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-0270
Mailing Address - Country:US
Mailing Address - Phone:208-934-4000
Mailing Address - Fax:208-886-2220
Practice Address - Street 1:120 SOUTH APPLE
Practice Address - Street 2:SUITE A
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352
Practice Address - Country:US
Practice Address - Phone:208-934-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID43300LS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164357OtherPK