Provider Demographics
NPI:1891783668
Name:DEBLAQUIERE ENTERPRISES INC
Entity Type:Organization
Organization Name:DEBLAQUIERE ENTERPRISES INC
Other - Org Name:WHITE CROSS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP. SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLASHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-448-1633
Mailing Address - Street 1:1319 HIGHWAY 2
Mailing Address - Street 2:STE A
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-2711
Mailing Address - Country:US
Mailing Address - Phone:208-263-9080
Mailing Address - Fax:208-255-1695
Practice Address - Street 1:1319 HIGHWAY 2 STE A
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-2729
Practice Address - Country:US
Practice Address - Phone:208-263-9080
Practice Address - Fax:208-255-1695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
ID1786RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807059400Medicaid
ID002464700Medicaid
2021876OtherPK
ID807059400Medicaid