Provider Demographics
NPI:1457739989
Name:HELLS CANYON HEALTH AND WELLNESS PHARMACY
Entity Type:Organization
Organization Name:HELLS CANYON HEALTH AND WELLNESS PHARMACY
Other - Org Name:HELLS CANYON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:POTTENGER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:208-743-5515
Mailing Address - Street 1:523 THAIN RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-5515
Mailing Address - Fax:208-743-0333
Practice Address - Street 1:523 THAIN RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-5515
Practice Address - Fax:208-743-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-17
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID38642RP3336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1457739989Medicaid