Provider Demographics
NPI:1578629069
Name:AMINI, JOHN MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:AMINI
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 1:4722 N EAGLE POINTE PL
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5361
Mailing Address - Country:US
Mailing Address - Phone:208-954-0309
Mailing Address - Fax:
Practice Address - Street 1:2790 W CHERRY LN STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1102
Practice Address - Country:US
Practice Address - Phone:208-288-1496
Practice Address - Fax:208-288-1812
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP67281835P0018X, 1835P1200X
WAPH 00016378183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy