Provider Demographics
NPI:1598868770
Name:WELL LIFE PHARMACY INCORPORATED
Entity Type:Organization
Organization Name:WELL LIFE PHARMACY INCORPORATED
Other - Org Name:WELL LIFE POST FALLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-267-4004
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1687
Mailing Address - Country:US
Mailing Address - Phone:208-267-8929
Mailing Address - Fax:208-267-8085
Practice Address - Street 1:565 N VEST ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7066
Practice Address - Country:US
Practice Address - Phone:208-773-2499
Practice Address - Fax:208-773-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
ID2161RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807728600Medicaid
WA6030860Medicaid
ID807722900Medicaid
2020945OtherPK
ID807722900Medicaid