Provider Demographics
NPI:1336737741
Name:PAOHENG, JITRUDEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JITRUDEE
Middle Name:
Last Name:PAOHENG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:873 E CREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4787
Mailing Address - Country:US
Mailing Address - Phone:208-473-0998
Mailing Address - Fax:
Practice Address - Street 1:932 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1711
Practice Address - Country:US
Practice Address - Phone:208-318-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8292183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist