NPIMap

Organization Active NPI

Medicine Man North Pharmacy Inc

  • Community/Retail Pharmacy
  • Hayden, ID
National Provider Identifier
1821159997
Registry record updated Jun 3, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
864RP Issued in ID
Legal business name
MEDICINE MAN NORTH PHARMACY INC
Practice address
240 W Hayden Ave
Hayden, ID 83835-8194
Phone
(208) 772-3311
Fax
(208) 772-1779
NPI assigned
Dec 13, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Korey E Kreider, PHARMD
Title
Coo
Phone
(208) 660-3938

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 864RP ID Primary

Addresses

Primary practice location

240 W Hayden Ave
Hayden, ID 83835-8194

Mailing address

PO Box 1706
Hayden, ID 83835-1706
Phone (208) 772-3311

Other identifiers 2

IdentifierTypeStateIssuer
1821159997MedicaidID
2020947OtherPK

Other names 1

  • MEDICINE MAN HAYDEN PHARMACY Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165968000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654214400000",
    "number": "1821159997",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1706",
            "city": "HAYDEN",
            "state": "ID",
            "postal_code": "838351706",
            "telephone_number": "208-772-3311",
            "fax_number": "208-772-1779"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "240 W HAYDEN AVE",
            "city": "HAYDEN",
            "state": "ID",
            "postal_code": "838358194",
            "telephone_number": "208-772-3311",
            "fax_number": "208-772-1779"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICINE MAN NORTH PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-13",
        "last_updated": "2022-06-03",
        "certification_date": "2022-06-03",
        "status": "A",
        "authorized_official_last_name": "KREIDER",
        "authorized_official_first_name": "KOREY",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "208-660-3938",
        "authorized_official_credential": "PHARMD"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "ID",
            "license": "864RP",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1821159997",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2020947",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MEDICINE MAN HAYDEN PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "MEDICINE MAN HAYDEN PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hayden, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.