Provider Demographics
NPI:1679082945
Name:LADD FAMILY PHARMACY LLC
Entity Type:Organization
Organization Name:LADD FAMILY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDEVALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-947-0877
Mailing Address - Street 1:1109 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3626
Mailing Address - Country:US
Mailing Address - Phone:208-947-0877
Mailing Address - Fax:
Practice Address - Street 1:2000 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3138
Practice Address - Country:US
Practice Address - Phone:208-947-0877
Practice Address - Fax:208-947-0874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LADD FAMILY PHARMACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46393LS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy