Provider Demographics
NPI:1285621136
Name:DEBLAQUIERE ENTERPRISES, INC.
Entity type:Organization
Organization Name:DEBLAQUIERE ENTERPRISES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORP. SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLASHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-448-1633
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:208-448-1728
Practice Address - Street 1:5453 HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856
Practice Address - Country:US
Practice Address - Phone:208-448-1633
Practice Address - Fax:208-448-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002464600Medicaid
ID002464700Medicaid
IDAW7540188OtherDEA LICENSE
IDAW7540188OtherDEA LICENSE