Healthcare Provider Details

I. General information

NPI: 1750442315
Provider Name (Legal Business Name): STATE OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 EAST ALICE STREET
BLACKFOOT ID
83221
US

IV. Provider business mailing address

700 EAST ALICE STREET PO BOX 400
BLACKFOOT ID
83221
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-1200
  • Fax: 208-785-8424
Mailing address:
  • Phone: 208-785-1200
  • Fax: 208-785-8424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number462HP
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number462HP
License Number StateID

VIII. Authorized Official

Name: MRS. TRACEY G. SESSIONS
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 208-785-8406