Provider Demographics
NPI:1124193487
Name:MEDICINE MAN WEST PHARMACY LLC
Entity Type:Organization
Organization Name:MEDICINE MAN WEST PHARMACY LLC
Other - Org Name:MEDICINE MAN WEST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-773-3566
Mailing Address - Street 1:802 E MEDICAL CT
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7298
Mailing Address - Country:US
Mailing Address - Phone:208-773-3566
Mailing Address - Fax:208-777-8239
Practice Address - Street 1:802 E MEDICAL CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7298
Practice Address - Country:US
Practice Address - Phone:208-773-3566
Practice Address - Fax:208-777-8239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
ID719CP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002599400Medicaid
ID20002785OtherMEDICARE PART B
1304411OtherNCPDP PROVIDER IDENTIFICATION NUMBER
ID002599400Medicaid
ID0487930001Medicare NSC