Active NPI
Medicine Man North Pharmacy Inc
- Community/Retail Pharmacy
- Hayden, ID
National Provider Identifier
1851894380
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- 47570RP
- Legal business name
- MEDICINE MAN NORTH PHARMACY INC
- Practice address
- 30585 N Roberts Rd
Hayden, ID 83835 - Phone
- (208) 683-1309
- Fax
- (208) 683-1315
- NPI assigned
- Mar 11, 2018
- Organization subpart
- No
NPPES NPI Registry
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) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 47570RP | ID | Primary |
Addresses
Primary practice location
30585 N Roberts Rd
Hayden, ID 83835
Mailing address
PO Box 1706
Hayden, ID 83835-1706
Phone (208) 683-1309
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851894380 | Medicaid | ID | |
| 2176449 | Other | PK |
Other names 1
- MEDICINE MAN ATHOL PHARMACY
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20081220000110 | ID | Part B Supplier - Mass Immunization (Roster Biller Only) | 2567524861 |
2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Coeur D Alene, ID; Hayden, ID; Athol, ID |
Other NPIs on the same Medicare enrollment 2
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
-
- Community/Retail Pharmacy
- Coeur D Alene, ID
- NPI 1649333261
O20081220000110
National Provider Directory
National Provider Directory- Tax ID family
- Medicine Man Athol Pharmacy
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Community/Retail Pharmacy
- Hayden, ID
- NPI 1023179892
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1520726400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1654214400000",
"number": "1851894380",
"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": "208-683-1309",
"fax_number": "208-683-1315"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "30585 N ROBERTS RD",
"city": "HAYDEN",
"state": "ID",
"postal_code": "83835",
"telephone_number": "208-683-1309",
"fax_number": "208-683-1315"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MEDICINE MAN NORTH PHARMACY INC",
"organizational_subpart": "NO",
"enumeration_date": "2018-03-11",
"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": "47570RP",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1851894380",
"state": "ID"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2176449",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "MEDICINE MAN ATHOL PHARMACY",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "MEDICINE MAN ATHOL 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.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.