Basic Information
| Provider Information | |||||||||
| NPI: | 1447669809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HYDE | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM D, R.PH. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUBBARD | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 SECOND ST SOUTH | ||||||||
| Address2: | |||||||||
| City: | NAMPA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084652836 | ||||||||
| FaxNumber: | 2084296427 | ||||||||
| Practice Location | |||||||||
| Address1: | 5230 W FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837051109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084296433 | ||||||||
| FaxNumber: | 2084296427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2014 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P7080 | ID | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.