Provider Demographics
NPI:1972633915
Name:MAAG PRESCRIPTION CENTER LLC
Entity type:Organization
Organization Name:MAAG PRESCRIPTION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:MAAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-2063
Mailing Address - Street 1:PO BOX 115
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-0115
Mailing Address - Country:US
Mailing Address - Phone:208-233-2063
Mailing Address - Fax:208-233-6158
Practice Address - Street 1:333 W. CENTER ST.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204
Practice Address - Country:US
Practice Address - Phone:208-233-2063
Practice Address - Fax:208-233-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID526CP3336C0003X, 3336C0004X
3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID526CPOtherST. BOARD OF PHARMACY #
ID002488900Medicaid
ID002488900Medicaid
1972633915Medicare NSC
1301718Medicare PIN