Provider Demographics
NPI:1053897843
Name:JUAREZ, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9372 W HALSTEAD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-6414
Mailing Address - Country:US
Mailing Address - Phone:208-490-2337
Mailing Address - Fax:
Practice Address - Street 1:5005 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2633
Practice Address - Country:US
Practice Address - Phone:208-389-1448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist