Organization
MEDICINE MAN NORTH PHARMACY INC
Active
Other names
MEDICINE MAN PRAIRIE PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
KOREY E KREIDER PHARMD (COO)
(208) 660-3938
Entity
Organization
Contact information
Practice address
8093 N CORNERSTONE DR, HAYDEN, ID 83835-8753
(208) 762-9355
(208) 762-9198
Mailing address
8093 N CORNERSTONE DR, HAYDEN, ID 83835-8753
(208) 762-9355
(208) 762-9198
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1308RP
ID
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1023179892
—
ID
01
—
2021452
PK
—
Enumeration date
12/13/2006
Last updated
06/03/2022
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