Provider Demographics
NPI:1366851388
Name:HENRY, ELISABETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E THORN ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WA
Mailing Address - Zip Code:99111-1613
Mailing Address - Country:US
Mailing Address - Phone:509-397-9130
Mailing Address - Fax:
Practice Address - Street 1:2740 WEST PULLMAN RD
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-882-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6261183500000X
WAPH60098255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist