Provider Demographics
NPI:1770833931
Name:GEDDES, ROBERT W (PHARMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GEDDES
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 1:4996 N BOTTICELLI AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3940
Practice Address - Country:US
Practice Address - Phone:208-513-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6687183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P6687OtherIDAHO BOARD OF PHARMACY
P6687OtherIDAHO BOARD OF PHARMACY