Provider Demographics
NPI:1912545971
Name:DAWE, RYAN GORDON
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:GORDON
Last Name:DAWE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12056 W FOXHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5953
Mailing Address - Country:US
Mailing Address - Phone:801-318-0921
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist