Provider Demographics
NPI:1437718111
Name:LOERA, ROSALBA
Entity Type:Individual
Prefix:
First Name:ROSALBA
Middle Name:
Last Name:LOERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSALVA
Other - Middle Name:
Other - Last Name:LOERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10565 W LAKE HAZEL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6326
Mailing Address - Country:US
Mailing Address - Phone:208-319-0882
Mailing Address - Fax:
Practice Address - Street 1:10565 W LAKE HAZEL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6326
Practice Address - Country:US
Practice Address - Phone:208-319-0882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist