Healthcare Provider Details

I. General information

NPI: 1457060790
Provider Name (Legal Business Name): IDAHO STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4914 YELLOWSTONE AVE STE B
CHUBBUCK ID
83202-2332
US

IV. Provider business mailing address

990 S 8TH AVE STOP 8158
POCATELLO ID
83201-4982
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-2005
  • Fax:
Mailing address:
  • Phone: 800-627-4781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA LEE ROCK
Title or Position: CLINICS DIRECTOR OF OPERATIONS
Credential:
Phone: 208-373-1743