Provider Demographics
NPI:1942747472
Name:TETON PHARMACY OF RIGBY LLC
Entity Type:Organization
Organization Name:TETON PHARMACY OF RIGBY LLC
Other - Org Name:TETON PHARMACY OF RIGBY
Other - Org Type:Doing Business As
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:
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:208-529-3636
Mailing Address - Fax:
Practice Address - Street 1:527 RIGBY LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5117
Practice Address - Country:US
Practice Address - Phone:208-745-9450
Practice Address - Fax:208-745-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID44146RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166778OtherPK