Provider Demographics
NPI:1386820314
Name:IRWIN DRUG INC.
Entity Type:Organization
Organization Name:IRWIN DRUG INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:GUY
Authorized Official - Last Name:JUNGERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-983-1090
Mailing Address - Street 1:146 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1932
Mailing Address - Country:US
Mailing Address - Phone:208-983-1090
Mailing Address - Fax:
Practice Address - Street 1:146 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1932
Practice Address - Country:US
Practice Address - Phone:208-983-1090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2081CP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807496800Medicaid
ID807496700OtherMEDICAID DME
ID807496800Medicaid