Provider Demographics
NPI:1851894380
Name:MEDICINE MAN NORTH PHARMACY INC
Entity Type:Organization
Organization Name:MEDICINE MAN NORTH PHARMACY INC
Other - Org Name:MEDICINE MAN ATHOL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KOREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KREIDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-660-3938
Mailing Address - Street 1:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1706
Mailing Address - Country:US
Mailing Address - Phone:208-683-1309
Mailing Address - Fax:208-683-1315
Practice Address - Street 1:30585 N ROBERTS RD
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-683-1309
Practice Address - Fax:208-683-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-11
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID47570RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1851894380Medicaid
2176449OtherPK