Provider Demographics
NPI:1184727240
Name:ROBERT LELAND COMSTOCK JR
Entity type:Organization
Organization Name:ROBERT LELAND COMSTOCK JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:COMSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-652-3932
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0710
Mailing Address - Country:US
Mailing Address - Phone:208-652-3932
Mailing Address - Fax:208-652-3470
Practice Address - Street 1:23 SOUTH 8TH STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420
Practice Address - Country:US
Practice Address - Phone:208-652-3932
Practice Address - Fax:208-652-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID1279RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1184727240Medicaid
2019741OtherPK