Provider Demographics
NPI:1497233563
Name:UPSHAW, ERNEST (PHARMD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:UPSHAW
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2484
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-2484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13020 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9330
Practice Address - Country:US
Practice Address - Phone:208-476-0110
Practice Address - Fax:208-476-0115
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2021-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist