Basic Information
Provider Information
NPI: 1003002965
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EVANS
FirstName: ELEANOR
MiddleName: I
NamePrefix:  
NameSuffix:  
Credential: R.PH.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5005 W OVERLAND RD
Address2:  
City: BOISE
State: ID
PostalCode: 837052633
CountryCode: US
TelephoneNumber: 2083891448
FaxNumber: 2083891458
Practice Location
Address1: 5005 W OVERLAND RD
Address2:  
City: BOISE
State: ID
PostalCode: 837052633
CountryCode: US
TelephoneNumber: 2083891448
FaxNumber: 2083891458
Other Information
ProviderEnumerationDate: 09/24/2007
LastUpdateDate: 09/24/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XP4040IDY Pharmacy Service ProvidersPharmacist 

No ID Information.


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