Provider Demographics
NPI:1285635169
Name:R & J PHARMACY, INC.
Entity Type:Organization
Organization Name:R & J PHARMACY, INC.
Other - Org Name:PHARMACY SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-785-3510
Mailing Address - Street 1:69 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2053
Mailing Address - Country:US
Mailing Address - Phone:208-785-3510
Mailing Address - Fax:208-785-7317
Practice Address - Street 1:69 N PINE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2053
Practice Address - Country:US
Practice Address - Phone:208-785-3510
Practice Address - Fax:208-785-7317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1907CP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1300514/8L386OtherBLUE CROSS
ID807034200Medicaid
ID807071700Medicaid
ID807034200Medicaid