Provider Demographics
NPI:1942558051
Name:EBRAHIMPOUR, JEREMY (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:EBRAHIMPOUR
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 W AUDUBON PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3852
Mailing Address - Country:US
Mailing Address - Phone:208-709-5793
Mailing Address - Fax:
Practice Address - Street 1:4364 W AUDUBON PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3852
Practice Address - Country:US
Practice Address - Phone:208-709-5793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist