Provider Demographics
NPI:1467517201
Name:KOMODA, NEIL TETSUO (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:NEIL
Middle Name:TETSUO
Last Name:KOMODA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8059
Mailing Address - Country:US
Mailing Address - Phone:208-523-2277
Mailing Address - Fax:208-552-1246
Practice Address - Street 1:2425 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8059
Practice Address - Country:US
Practice Address - Phone:208-523-2277
Practice Address - Fax:208-552-1246
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3674183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID421CPOtherLICENSE
5386640001Medicare ID - Type Unspecified