Organization
MEDICINE MAN PHARMACY INC
Active
Other names
MEDICINE MAN PHARMACY INC
Organization subpart
No
Provider details
NPI number
Authorized official
BRIAN JORGENSEN RPH (PRESIDENT)
(208) 666-2502
Entity
Organization
Contact information
Practice address
1114 W IRONWOOD DR, COEUR D ALENE, ID 83814-2605
(208) 666-2502
(208) 667-5921
Mailing address
1114 W IRONWOOD DR, COEUR D ALENE, ID 83814-2605
(208) 666-2502
(208) 667-5921
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
657RP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002541100
—
ID
05
—
002541200
—
ID
01
—
2020458
PK
—
Enumeration date
08/31/2006
Last updated
07/01/2013
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