Provider Demographics
NPI:1780665463
Name:RED CROSS PHARMACY INC
Entity Type:Organization
Organization Name:RED CROSS PHARMACY INC
Other - Org Name:RED CROSS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:B PHARM
Authorized Official - Phone:208-289-5941
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:KENDRICK
Mailing Address - State:ID
Mailing Address - Zip Code:83537-0131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDRICK
Practice Address - State:ID
Practice Address - Zip Code:83537-0131
Practice Address - Country:US
Practice Address - Phone:208-289-5941
Practice Address - Fax:208-289-5942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID865RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002709100Medicaid
2020091OtherPK