Provider Demographics
NPI:1376207696
Name:GOSTANTIAN, ARTOUN
Entity Type:Individual
Prefix:
First Name:ARTOUN
Middle Name:
Last Name:GOSTANTIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10006 W SMOKE RANCH DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1200
Mailing Address - Country:US
Mailing Address - Phone:916-513-9026
Mailing Address - Fax:
Practice Address - Street 1:4110 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5706
Practice Address - Country:US
Practice Address - Phone:208-402-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP9624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID018322Medicaid