Basic Information
Provider Information | |||||||||
NPI: | 1881224327 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST LUKES MAGIC VALLEY REGIONAL MEDICAL CENTER LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST LUKES MAGIC VALLEY RETAIL PHARMACY DISPENSER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2777 | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837012777 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088141000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 801 POLE LINE RD W | ||||||||
Address2: |   | ||||||||
City: | TWIN FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 833015810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088141000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2020 | ||||||||
LastUpdateDate: | 04/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLEVERLEY | ||||||||
AuthorizedOfficialFirstName: | JANINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REVENUE CYCLE ANALYST / ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 2087064367 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ST LUKE'S MAGIC VALLEY REGIONAL MEDICAL CENTER LTD | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.