Provider Demographics
NPI:1265515357
Name:LOST RIVERS HOSPITAL PHARMACY
Entity type:Organization
Organization Name:LOST RIVERS HOSPITAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-527-8206
Mailing Address - Street 1:PO BOX 145
Mailing Address - Street 2:
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213-0145
Mailing Address - Country:US
Mailing Address - Phone:208-527-8206
Mailing Address - Fax:208-527-3105
Practice Address - Street 1:551 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:ARCO
Practice Address - State:ID
Practice Address - Zip Code:83213
Practice Address - Country:US
Practice Address - Phone:208-527-8206
Practice Address - Fax:208-527-3105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOST RIVERS DISTRICT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807065100Medicaid
ID135061Medicare Oscar/Certification