Provider Demographics
NPI:1730638172
Name:BIRCH, ROBERT GRAY (PHARMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GRAY
Last Name:BIRCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 W 2ND S
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-1509
Mailing Address - Country:US
Mailing Address - Phone:208-547-3300
Mailing Address - Fax:208-547-3532
Practice Address - Street 1:89 W 2ND S
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1509
Practice Address - Country:US
Practice Address - Phone:208-547-3300
Practice Address - Fax:208-547-3532
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist