Active NPI
Travis Walthall, RPH
- Pharmacist
- Kuna, ID
National Provider Identifier
1144566894
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- P5435
- Practice address
- 173 W 4TH St
Kuna, ID 83634-2046 - Phone
- (208) 922-4400
- Fax
- (208) 922-4499
- NPI assigned
- Dec 28, 2012
- Last updated
- Dec 28, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | P5435 | ID | Primary |
Addresses
Primary practice location
173 W 4TH St
Kuna, ID 83634-2046
Mailing address
173 W 4TH St
PO Box 246
Kuna, ID 83634-2046
Phone (208) 922-4400
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| P5435 | ID | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Custom RX | Current | Accepting new patients | |
| Custom RX LLC | Current | Accepting new patients |
Locations
173 W 4th St
Kuna, ID 83634
Phone (208) 922-4400
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Pharmacy
- Kuna, ID
- NPI 1669460093
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1356652800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1356652800000",
"number": "1144566894",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "173 W 4TH ST",
"address_2": "PO BOX 246",
"city": "KUNA",
"state": "ID",
"postal_code": "836342046",
"telephone_number": "208-922-4400",
"fax_number": "208-922-4499"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "173 W 4TH ST",
"city": "KUNA",
"state": "ID",
"postal_code": "836342046",
"telephone_number": "208-922-4400",
"fax_number": "208-922-4499"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALTHALL",
"first_name": "TRAVIS",
"credential": "RPH",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-12-28",
"last_updated": "2012-12-28",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "ID",
"license": "P5435",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Kuna, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.