Provider Demographics
NPI:1932635810
Name:TETON PHARMACY OF ST ANTHONY
Entity Type:Organization
Organization Name:TETON PHARMACY OF ST ANTHONY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:208-529-3636
Mailing Address - Street 1:2470 JAFER CT
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5587
Mailing Address - Country:US
Mailing Address - Phone:208-624-4411
Mailing Address - Fax:208-624-4412
Practice Address - Street 1:104 N BRIDGE ST
Practice Address - Street 2:SUITE 112
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1455
Practice Address - Country:US
Practice Address - Phone:208-624-4411
Practice Address - Fax:208-624-4412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID45043LS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy