Provider Demographics
NPI:1265425433
Name:WALLENTINE, DEAN A (PHARM D)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:A
Last Name:WALLENTINE
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 1:836 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1423
Mailing Address - Country:US
Mailing Address - Phone:208-847-1421
Mailing Address - Fax:208-847-1690
Practice Address - Street 1:836 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1423
Practice Address - Country:US
Practice Address - Phone:208-847-1421
Practice Address - Fax:208-847-1690
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5441183500000X, 332B00000X
ID1440CP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116208000Medicaid
ID805479000Medicaid
UT820513714009Medicaid
ID1303730001Medicare NSC
ID8F652OtherBLUE CROSS OF IDAHO