Provider Demographics
NPI:1932977600
Name:IDAHO PHARMACY, LLC
Entity Type:Organization
Organization Name:IDAHO PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, PHARMD
Authorized Official - Phone:208-965-9105
Mailing Address - Street 1:1079 S ANCONA AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5539
Mailing Address - Country:US
Mailing Address - Phone:208-965-9105
Mailing Address - Fax:
Practice Address - Street 1:1079 S ANCONA AVE STE 140
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5539
Practice Address - Country:US
Practice Address - Phone:208-965-9105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy