Provider Demographics
NPI:1245781574
Name:FRED MEYER PHARMACY
Entity Type:Organization
Organization Name:FRED MEYER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:KREUZER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:1208-736-5373
Mailing Address - Street 1:705 BLUE LAKES BLVD N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4007
Mailing Address - Country:US
Mailing Address - Phone:120-873-6537
Mailing Address - Fax:
Practice Address - Street 1:705 BLUE LAKES BLVD N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4007
Practice Address - Country:US
Practice Address - Phone:120-873-6537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5593261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health