Provider Demographics
NPI:1386747558
Name:WELL LIFE PHARMACY INCORPORATED
Entity type:Organization
Organization Name:WELL LIFE PHARMACY INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-267-4004
Mailing Address - Street 1:PO BOX 1687
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1687
Mailing Address - Country:US
Mailing Address - Phone:208-267-8929
Mailing Address - Fax:208-267-8085
Practice Address - Street 1:5608 S REGAL ST STE 102
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7957
Practice Address - Country:US
Practice Address - Phone:509-838-0896
Practice Address - Fax:509-838-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHAR.CF.605866273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6030597Medicaid
ID807728700Medicaid
WA807723000Medicaid
2110399OtherPK
WA6030597Medicaid