Provider Demographics
NPI:1730926080
Name:GEM STATE PHARMACY LLC
Entity type:Organization
Organization Name:GEM STATE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-329-6104
Mailing Address - Street 1:1516 W BLUE DOWNS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8496
Mailing Address - Country:US
Mailing Address - Phone:208-329-6104
Mailing Address - Fax:208-609-6290
Practice Address - Street 1:1437 PARK VIEW DR # 200
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3250
Practice Address - Country:US
Practice Address - Phone:208-329-6104
Practice Address - Fax:208-609-6290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-12
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy