Provider Demographics
NPI:1912515560
Name:HANCOCK, GRETCHEN KLETZER
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:KLETZER
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 N KRISTEN WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1231
Mailing Address - Country:US
Mailing Address - Phone:541-604-5275
Mailing Address - Fax:
Practice Address - Street 1:179 W HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9737
Practice Address - Country:US
Practice Address - Phone:208-272-9454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCT37441183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician