Provider Demographics
NPI:1306187372
Name:SMITH, DAVE MARTIN (BS PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:DAVE
Middle Name:MARTIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W RESSEGUIE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4438
Mailing Address - Country:US
Mailing Address - Phone:208-371-9912
Mailing Address - Fax:
Practice Address - Street 1:8001 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3695
Practice Address - Country:US
Practice Address - Phone:847-588-7474
Practice Address - Fax:847-588-7060
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID44212183500000X
TX51023183500000X
ORRPH-0012414-P183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist