Provider Demographics
NPI:1609202068
Name:BOROVATZ, IAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:BOROVATZ
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 1:3395 S. FEDERAL WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-8844
Mailing Address - Country:US
Mailing Address - Phone:208-319-1043
Mailing Address - Fax:
Practice Address - Street 1:3395 S. FEDERAL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-8844
Practice Address - Country:US
Practice Address - Phone:208-319-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5737114-1701183500000X
IDP6894183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist