Provider Demographics
NPI:1740584051
Name:PHARMA DONNA LLC
Entity Type:Organization
Organization Name:PHARMA DONNA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARM D
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SWINK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-450-9085
Mailing Address - Street 1:PO BOX 6464
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6464
Mailing Address - Country:US
Mailing Address - Phone:208-726-2679
Mailing Address - Fax:
Practice Address - Street 1:201 N. WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-2679
Practice Address - Fax:208-726-1179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336C0004X
ID16297RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127936OtherPK
ID1740584051Medicaid