Provider Demographics
NPI:1679720387
Name:REA, JOEL (RPH)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:
Last Name:REA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-0700
Mailing Address - Country:US
Mailing Address - Phone:208-756-5675
Mailing Address - Fax:208-756-5757
Practice Address - Street 1:203 S DAISY
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-0700
Practice Address - Country:US
Practice Address - Phone:208-756-5675
Practice Address - Fax:208-756-5757
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist