Provider Demographics
NPI:1144993395
Name:DILLON, PATRICIA ANN
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:DILLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICK
Other - Middle Name:ANN
Other - Last Name:DILLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:223 BAKER ST APT 103
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4037
Mailing Address - Country:US
Mailing Address - Phone:208-440-5180
Mailing Address - Fax:
Practice Address - Street 1:223 BAKER ST APT 103
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4037
Practice Address - Country:US
Practice Address - Phone:208-440-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDT60944183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1210518OtherPTCB ACCOUNT ID
1444516OtherNABP E-PROFILE ID