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General NPI Number Information
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NPI Number | 1750442315
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Entity Type | Organization
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Legal Business Name | STATE OF IDAHO
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 700 EAST ALICE STREET
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City | BLACKFOOT
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State | ID
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Zip | 83221
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Country | US
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Telephone | 208-785-1200
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Fax | 208-785-8424
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Provider Business Mailing Address
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Address Line | 700 EAST ALICE STREET PO BOX 400
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City | BLACKFOOT
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State | ID
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Zip | 83221
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Country | US
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Telephone | 208-785-1200
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Fax | 208-785-8424
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Authorized Official
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Title or Position | ADMINISTRATIVE DIRECTOR
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Name | MRS. TRACEY G. SESSIONS
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Credential |
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Telephone | 208-785-8406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 462HP
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 462HP
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License Number State | ID
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