Provider Demographics
NPI:1760564553
Name:ONTARIO PHARMACY INC
Entity Type:Organization
Organization Name:ONTARIO PHARMACY INC
Other - Org Name:PARK-VU PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-452-7075
Mailing Address - Street 1:1118 NW 16TH ST # 150
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2271
Mailing Address - Country:US
Mailing Address - Phone:208-452-7075
Mailing Address - Fax:208-452-7446
Practice Address - Street 1:1118 NW 16TH ST # 150
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2271
Practice Address - Country:US
Practice Address - Phone:208-452-7075
Practice Address - Fax:208-452-7446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID36033RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020336OtherPK
ID003355000Medicaid
ID002430360Medicaid