Provider Demographics
NPI:1184908394
Name:FISHER, DALLEN (RPH)
Entity type:Individual
Prefix:MR
First Name:DALLEN
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:DALLEN
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:659 CROCUS LN
Mailing Address - Street 2:
Mailing Address - City:PAUL
Mailing Address - State:ID
Mailing Address - Zip Code:83347-8600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 BLUE LAKES BLVD N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4827
Practice Address - Country:US
Practice Address - Phone:208-734-4053
Practice Address - Fax:208-734-4295
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist