Provider Demographics
NPI:1992080154
Name:MITCHELL, MORGAN WADE (RPH)
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:WADE
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8576
Mailing Address - Country:US
Mailing Address - Phone:208-465-5911
Mailing Address - Fax:
Practice Address - Street 1:2219 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6313
Practice Address - Country:US
Practice Address - Phone:208-318-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4697183500000X
WY2217183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist