Provider Demographics
NPI:1295847135
Name:REDDISH PHARMACY INC
Entity Type:Organization
Organization Name:REDDISH PHARMACY INC
Other - Org Name:REDDISH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-466-7823
Mailing Address - Street 1:215 E HAWAII AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-466-7823
Mailing Address - Fax:208-466-8429
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:STE 100
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-466-7823
Practice Address - Fax:208-466-8429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID693RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002584300Medicaid
2020587OtherPK