Healthcare Provider Details

I. General information

NPI: 1356275796
Provider Name (Legal Business Name): COMMUNITY COUNCIL OF IDAHO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 ALAN ST
IDAHO FALLS ID
83404-5801
US

IV. Provider business mailing address

2100 ALAN ST
IDAHO FALLS ID
83404-5801
US

V. Phone/Fax

Practice location:
  • Phone: 208-470-7979
  • Fax: 888-626-5801
Mailing address:
  • Phone: 208-470-7979
  • Fax: 888-626-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TROY COULSON
Title or Position: PHARMACY OPERATIONS OFFICER
Credential: PHARMD
Phone: 208-470-7979