Provider Demographics
NPI:1407966229
Name:INNOVATIVE CARE PHARMACY
Entity Type:Organization
Organization Name:INNOVATIVE CARE PHARMACY
Other - Org Name:INNOVATIVE CARE PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PURCHASING
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-552-7630
Mailing Address - Street 1:9196 W EMERALD ST
Mailing Address - Street 2:STE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-0679
Mailing Address - Country:US
Mailing Address - Phone:208-323-1259
Mailing Address - Fax:208-323-8934
Practice Address - Street 1:9196 W EMERALD ST
Practice Address - Street 2:STE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0679
Practice Address - Country:US
Practice Address - Phone:208-323-1259
Practice Address - Fax:208-323-8934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2303CP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806967700Medicaid
1307619OtherNCPDP PROVIDER IDENTIFICATION NUMBER
ID806967700Medicaid