Provider Demographics
NPI:1487711065
Name:TETON CLINICAL PHARMACY, INC.
Entity type:Organization
Organization Name:TETON CLINICAL PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-3636
Mailing Address - Street 1:2470 JAFER CT
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-529-3636
Mailing Address - Fax:208-529-1715
Practice Address - Street 1:2470 JAFER CT.
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-529-3636
Practice Address - Fax:208-529-1715
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TETON PHARMACY HOME HEALTH & HOSPICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002551800Medicaid
0615470001Medicare PIN
ID0615470001Medicare NSC