Provider Demographics
NPI:1578826178
Name:MEDICINE MAN BONNERS FERRY PHARMACY LLC
Entity Type:Organization
Organization Name:MEDICINE MAN BONNERS FERRY PHARMACY LLC
Other - Org Name:MEDICINE MAN BONNERS FERRY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:STUERMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-627-8861
Mailing Address - Street 1:6452 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8520
Mailing Address - Country:US
Mailing Address - Phone:208-267-4021
Mailing Address - Fax:208-267-4024
Practice Address - Street 1:6452 MAIN ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8520
Practice Address - Country:US
Practice Address - Phone:208-267-4021
Practice Address - Fax:208-267-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID37603RP3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1578826178Medicaid
ID1578826178Medicaid
2150407OtherPK