Provider Demographics
NPI:1205164126
Name:BALLANCE, PHILIP ANDERS
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:ANDERS
Last Name:BALLANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W EMMA AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2531
Mailing Address - Country:US
Mailing Address - Phone:208-665-1700
Mailing Address - Fax:208-667-8649
Practice Address - Street 1:915 W EMMA AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2531
Practice Address - Country:US
Practice Address - Phone:208-665-1700
Practice Address - Fax:208-667-8649
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5974183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist