Provider Demographics
NPI:1619393493
Name:WILLIS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist