Provider Demographics
NPI:1861829020
Name:FOGLE, JAROM B (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAROM
Middle Name:B
Last Name:FOGLE
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 1:8100 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8425
Mailing Address - Country:US
Mailing Address - Phone:208-375-2825
Mailing Address - Fax:208-375-2846
Practice Address - Street 1:8100 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8425
Practice Address - Country:US
Practice Address - Phone:208-375-2825
Practice Address - Fax:208-375-2846
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist