Provider Demographics
NPI:1194219634
Name:NEIBAUR, JERAMY RANDALL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JERAMY
Middle Name:RANDALL
Last Name:NEIBAUR
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 1:1111 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2111
Mailing Address - Country:US
Mailing Address - Phone:208-313-2816
Mailing Address - Fax:
Practice Address - Street 1:103 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2247
Practice Address - Country:US
Practice Address - Phone:208-245-4578
Practice Address - Fax:208-245-5004
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP80331835P1200X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy