Provider Demographics
NPI:1174003305
Name:TABACCHI, ALYSA LEI MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALYSA
Middle Name:LEI MARIE
Last Name:TABACCHI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2043 W SOLDOTNA ST
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-5315
Mailing Address - Country:US
Mailing Address - Phone:808-343-7940
Mailing Address - Fax:
Practice Address - Street 1:1650 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4040
Practice Address - Country:US
Practice Address - Phone:208-344-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist