| NPI | 1366488983 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIFFANY ELIOPULOS Assistant Manager, Enrollments 208-395-3906 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 3336C0003X Pharmacy Community/Retail Pharmacy |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 22177) |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2018-11-02 |