Cody Sean Deforest
Individual provider Active NPI Pharmacist · Salmon, ID
NPI 1679259121 · NPPES record last updated Jun 27, 2023
Key facts
- NPI
- 1679259121
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- P10698 (ID)
- Practice address
- 309 Main St
Salmon, ID 83467-4114 - Phone
- (208) 742-3784
- NPI assigned
- Jun 27, 2023
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| P10698 | ID | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Salmon Pharmacy, LLC | Current |
Accepting new patients |
Locations
309 Main St
Salmon, ID 83467
Phone (208) 742-3784
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | P10698 | ID | Yes |
Addresses
Primary practice location
309 Main St
Salmon, ID 83467-4114
Mailing address
309 Main St
Salmon, ID 83467-4114
Other providers in Salmon, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 27, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.