Basic Information
| Provider Information | |||||||||
| NPI: | 1437191418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTNEUF MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | PORTNEUF PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 651 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391000 | ||||||||
| FaxNumber: | 2082391970 | ||||||||
| Practice Location | |||||||||
| Address1: | 651 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391000 | ||||||||
| FaxNumber: | 2082391970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILKER | ||||||||
| AuthorizedOfficialFirstName: | JOHNATHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2082391020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | H12 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
No ID Information.