Provider Demographics
NPI:1730694621
Name:CARNEY, JUSTIN DALE SR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DALE
Last Name:CARNEY
Suffix:SR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1570 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1821
Mailing Address - Country:US
Mailing Address - Phone:208-888-0034
Mailing Address - Fax:208-887-1332
Practice Address - Street 1:1570 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1821
Practice Address - Country:US
Practice Address - Phone:208-888-0034
Practice Address - Fax:208-887-1332
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017771183500000X
IDP7861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist