Provider Demographics
NPI:1669460093
Name:VIC'S FAMILY PHARMACY INC
Entity Type:Organization
Organization Name:VIC'S FAMILY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-922-4400
Mailing Address - Street 1:119 S VALLEY DR STE A
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2985
Mailing Address - Country:US
Mailing Address - Phone:208-922-4400
Mailing Address - Fax:208-922-4499
Practice Address - Street 1:173 E 4TH ST
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2103
Practice Address - Country:US
Practice Address - Phone:208-922-4400
Practice Address - Fax:208-922-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1271CP333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8044295400Medicaid
ID1271CPOtherBOARD OF PHARMACY
ID1306251OtherNATL ASSO BOARD OF PHARMA