Provider Demographics
NPI:1821474818
Name:THIBODEAU, MARY (PHARMD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 228
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4473
Mailing Address - Country:US
Mailing Address - Phone:208-625-5672
Mailing Address - Fax:208-625-6488
Practice Address - Street 1:700 W IRONWOOD DR STE 228
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4473
Practice Address - Country:US
Practice Address - Phone:208-625-5672
Practice Address - Fax:208-625-6488
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH600204861835P0018X
IDP81071835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist