Provider Demographics
NPI:1033917810
Name:PURE PATH COMPOUNDING PHARMACY LLC
Entity type:Organization
Organization Name:PURE PATH COMPOUNDING PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-985-3575
Mailing Address - Street 1:2141 W AIRPORT WAY STE 700
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2141 W AIRPORT WAY STE 700
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5168
Practice Address - Country:US
Practice Address - Phone:208-985-3575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-06
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy