Provider Demographics
NPI:1679639462
Name:PHARMACY SHOP INC
Entity Type:Organization
Organization Name:PHARMACY SHOP INC
Other - Org Name:SNELLS IV & COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SNELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH CCN
Authorized Official - Phone:208-232-0049
Mailing Address - Street 1:1015 E YOUNG
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-0049
Mailing Address - Fax:208-232-3963
Practice Address - Street 1:1015 E YOUNG
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-0049
Practice Address - Fax:208-232-3963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0470300003Medicare ID - Type Unspecified