Provider Demographics
NPI:1083794598
Name:ST ALPHONSUS REGIONAL MED
Entity Type:Organization
Organization Name:ST ALPHONSUS REGIONAL MED
Other - Org Name:PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO AND BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LANNIE
Authorized Official - Last Name:CHECKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-367-7347
Mailing Address - Street 1:1055 N CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1309
Mailing Address - Country:US
Mailing Address - Phone:208-367-3069
Mailing Address - Fax:208-367-3016
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-367-3069
Practice Address - Fax:208-367-3016
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST ALPHONSUS REGIONAL MED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-17
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1000450001Medicare NSC