Organization
MEDICINE MAN NORTH PHARMACY INC
Active
Other names
MEDICINE MAN ATHOL PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
KOREY E KREIDER PHARMD (COO)
(208) 660-3938
Entity
Organization
Contact information
Practice address
30585 N ROBERTS RD, HAYDEN, ID 83835
(208) 683-1309
(208) 683-1315
Mailing address
PO BOX 1706, HAYDEN, ID 83835-1706
(208) 683-1309
(208) 683-1315
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
47570RP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1851894380
—
ID
01
—
2176449
PK
—
Enumeration date
03/11/2018
Last updated
06/03/2022
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