Basic Information
| Provider Information | |||||||||
| NPI: | 1104475870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURDOCK | ||||||||
| FirstName: | KAYSIE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNO | ||||||||
| OtherFirstName: | KAYSIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6565 W EMERALD ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142512 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 W EMERALD ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085142512 | ||||||||
| FaxNumber: | 2083752217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2019 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P8560 | ID | Y | Pharmacy Service Providers | Pharmacist | 390200000X | E38936 | ID | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.