Provider Demographics
NPI:1063508018
Name:ROCKLAND PHARMACY, INC
Entity Type:Organization
Organization Name:ROCKLAND PHARMACY, INC
Other - Org Name:ROCKLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-226-2411
Mailing Address - Street 1:524 TYHEE AVE
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-1224
Mailing Address - Country:US
Mailing Address - Phone:208-226-2411
Mailing Address - Fax:208-226-5124
Practice Address - Street 1:524 TYHEE AVE
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1224
Practice Address - Country:US
Practice Address - Phone:208-226-2411
Practice Address - Fax:208-226-5124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0347100001Medicaid
2019639OtherPK
ID002398900Medicaid
ID00239900Medicaid