Provider Demographics
NPI:1366738718
Name:LEE, RICK D
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:D
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RICKIE
Other - Middle Name:DONALD
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:4038 W QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3850
Mailing Address - Country:US
Mailing Address - Phone:208-343-2687
Mailing Address - Fax:208-343-2687
Practice Address - Street 1:7100 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-7497
Practice Address - Country:US
Practice Address - Phone:208-841-1160
Practice Address - Fax:208-336-6424
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP3646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP3646OtherPHARMACY LICENSE