Provider Demographics
NPI:1184819955
Name:WELLS, SHAUN JEFFREY (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:JEFFREY
Last Name:WELLS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 W BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1912
Mailing Address - Country:US
Mailing Address - Phone:208-785-8000
Mailing Address - Fax:208-785-9624
Practice Address - Street 1:960 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1912
Practice Address - Country:US
Practice Address - Phone:208-785-8000
Practice Address - Fax:208-785-9624
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist