Provider Demographics
NPI:1386114031
Name:TIPTON, DESTINI (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DESTINI
Middle Name:
Last Name:TIPTON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:DESTINI
Other - Middle Name:
Other - Last Name:DAVID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-7282
Mailing Address - Fax:208-381-4355
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-7282
Practice Address - Fax:208-381-4355
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist