Provider Demographics
NPI:1134391121
Name:LADD FAMILY PHARMACY LLC
Entity type:Organization
Organization Name:LADD FAMILY PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDEVALL
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:208-947-0877
Mailing Address - Street 1:1109 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3626
Mailing Address - Country:US
Mailing Address - Phone:208-947-0877
Mailing Address - Fax:208-947-0874
Practice Address - Street 1:1109 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3626
Practice Address - Country:US
Practice Address - Phone:208-947-0877
Practice Address - Fax:208-947-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-30
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
ID38076RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022000OtherPK
IDM8081177Medicaid
IDM8081035Medicaid