Provider Demographics
NPI:1225860885
Name:BUMGARDNER, EMALIE (PHARMD)
Entity type:Individual
Prefix:
First Name:EMALIE
Middle Name:
Last Name:BUMGARDNER
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:PO BOX 1063
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-1063
Mailing Address - Country:US
Mailing Address - Phone:208-512-5693
Mailing Address - Fax:
Practice Address - Street 1:583 COMMERCE DRIVE
Practice Address - Street 2:
Practice Address - City:SMELTERVILLE
Practice Address - State:ID
Practice Address - Zip Code:83868-0000
Practice Address - Country:US
Practice Address - Phone:208-783-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDI58719390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program