Provider Demographics
NPI:1720325848
Name:LEIBOWITZ, INDRA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:INDRA
Middle Name:
Last Name:LEIBOWITZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:INDRA
Other - Middle Name:
Other - Last Name:HUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH, ND
Mailing Address - Street 1:4621 N SETTLERS RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-7013
Mailing Address - Country:US
Mailing Address - Phone:208-995-9760
Mailing Address - Fax:
Practice Address - Street 1:600 E BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-995-9760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6335183500000X
CA42805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist