Provider Demographics
NPI:1497041313
Name:BAXTER, BRENT (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:BAXTER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4254
Mailing Address - Country:US
Mailing Address - Phone:208-466-3592
Mailing Address - Fax:208-463-1392
Practice Address - Street 1:715 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4254
Practice Address - Country:US
Practice Address - Phone:208-466-3592
Practice Address - Fax:208-463-1392
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist