Provider Demographics
NPI:1659700896
Name:ONTARIO PHARMACY INC
Entity Type:Organization
Organization Name:ONTARIO PHARMACY INC
Other - Org Name:VALLEY COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-452-3340
Mailing Address - Street 1:1118 NW 16TH ST # 150B
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2271
Mailing Address - Country:US
Mailing Address - Phone:208-452-3340
Mailing Address - Fax:208-452-7446
Practice Address - Street 1:1118 NW 16TH ST # 150B
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2271
Practice Address - Country:US
Practice Address - Phone:208-452-3340
Practice Address - Fax:208-452-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-08
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X
ID21811LS3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142790OtherPK