Provider Demographics
NPI:1104828870
Name:SNELL, ED (RPH)
Entity Type:Individual
Prefix:
First Name:ED
Middle Name:
Last Name:SNELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 E YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5282
Mailing Address - Country:US
Mailing Address - Phone:208-232-0049
Mailing Address - Fax:208-232-3963
Practice Address - Street 1:1015 E YOUNG ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5282
Practice Address - Country:US
Practice Address - Phone:208-232-0049
Practice Address - Fax:208-232-3963
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP40331835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support