Provider Demographics
NPI:1184045791
Name:EKE HAGESTAD, SALLY ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ANN
Last Name:EKE HAGESTAD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34987 JACKS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LENORE
Mailing Address - State:ID
Mailing Address - Zip Code:83541-6264
Mailing Address - Country:US
Mailing Address - Phone:208-816-6770
Mailing Address - Fax:
Practice Address - Street 1:34987 JACKS CANYON RD
Practice Address - Street 2:
Practice Address - City:LENORE
Practice Address - State:ID
Practice Address - Zip Code:83541-6264
Practice Address - Country:US
Practice Address - Phone:208-816-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist