Provider Demographics
NPI:1154800522
Name:VESTAL, JOANNE (PHARMD)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:VESTAL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2434
Mailing Address - Country:US
Mailing Address - Phone:208-799-5626
Mailing Address - Fax:208-799-5424
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2434
Practice Address - Country:US
Practice Address - Phone:208-799-5626
Practice Address - Fax:208-799-5424
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist