Provider Demographics
NPI:1851677827
Name:THE HOSPICE STORE AND SUPPLIES
Entity Type:Organization
Organization Name:THE HOSPICE STORE AND SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:BOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-251-1032
Mailing Address - Street 1:134 N 3966 E
Mailing Address - Street 2:ADDRESS 2
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5772
Mailing Address - Country:US
Mailing Address - Phone:208-251-1032
Mailing Address - Fax:208-745-8739
Practice Address - Street 1:134 N 3966 E
Practice Address - Street 2:ADDRESS 2
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5772
Practice Address - Country:US
Practice Address - Phone:208-251-1032
Practice Address - Fax:208-745-8739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-22
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME16726332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies