Organization
BEAR LAKE DRUG LLC
Active
Other names
Bear Lake Drug L.L.C.
Organization subpart
No
Provider details
NPI number
Authorized official
CASEY HUMPHERYS (PHARMD)
(208) 847-1421
Entity
Organization
Contact information
Practice address
836 WASHINGTON ST, MONTPELIER, ID 83254-1423
(208) 847-1421
(208) 847-1690
Mailing address
836 WASHINGTON ST, MONTPELIER, ID 83254-1423
(208) 847-1421
(208) 847-1690
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1440RP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2147038
PK
—
Enumeration date
06/18/2014
Last updated
01/18/2017
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