Provider Demographics
NPI:1962581652
Name:MEDICAL CLINIC PHARMACY INC
Entity type:Organization
Organization Name:MEDICAL CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-459-1503
Mailing Address - Street 1:315 E ELM ST
Mailing Address - Street 2:SUITE150
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4857
Mailing Address - Country:US
Mailing Address - Phone:208-459-1503
Mailing Address - Fax:208-459-1504
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:SUITE150
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4857
Practice Address - Country:US
Practice Address - Phone:208-459-1503
Practice Address - Fax:208-459-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
ID2373RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1962581652Medicaid
2123594OtherPK