Provider Demographics
NPI:1699177527
Name:KOUDELKA, JEFFREY (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:KOUDELKA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1838
Mailing Address - Country:US
Mailing Address - Phone:208-934-4709
Mailing Address - Fax:208-934-4905
Practice Address - Street 1:1427 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1838
Practice Address - Country:US
Practice Address - Phone:208-934-4709
Practice Address - Fax:208-934-4905
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist