Provider Demographics
NPI:1164793766
Name:TOMINAGA, JASON ANDREW
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANDREW
Last Name:TOMINAGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 S ICE BEAR WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8161
Mailing Address - Country:US
Mailing Address - Phone:208-431-1414
Mailing Address - Fax:
Practice Address - Street 1:8100 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8425
Practice Address - Country:US
Practice Address - Phone:208-375-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist