Provider Demographics
NPI:1831561034
Name:TETON PHARMACY IN AMMON
Entity type:Organization
Organization Name:TETON PHARMACY IN AMMON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-529-3638
Mailing Address - Street 1:2470 JAFER CT
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5587
Mailing Address - Country:US
Mailing Address - Phone:208-529-3636
Mailing Address - Fax:208-529-1715
Practice Address - Street 1:3160 E 17TH ST STE 164
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6784
Practice Address - Country:US
Practice Address - Phone:208-529-1795
Practice Address - Fax:208-529-1838
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON CLINICAL PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-27
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1831561034Medicaid
2154929OtherPK
ID1043629397Medicaid