Provider Demographics
NPI:1285313239
Name:PURYEAR, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:PURYEAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-0458
Mailing Address - Country:US
Mailing Address - Phone:208-448-1633
Mailing Address - Fax:
Practice Address - Street 1:86 TANK RD
Practice Address - Street 2:
Practice Address - City:OLDTOWN
Practice Address - State:ID
Practice Address - Zip Code:83822-5126
Practice Address - Country:US
Practice Address - Phone:208-457-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist