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General NPI Number Information
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NPI Number | 1992726962
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Entity Type | Organization
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Legal Business Name | BYU ID STUDENT HLTH CNTR PCHY
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Dates
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Enumeration Date | 07/22/2006
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Last Update Date | 04/18/2017
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Provider Practice Location Address
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Address Line | 179 STUDENT HLTH CTR
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City | REXBURG
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State | ID
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Zip | 83460-0001
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Country | US
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Telephone | 208-496-9330
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Fax | 208-496-9343
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Provider Business Mailing Address
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Address Line | 179 STUDENT HLTH CTR
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City | REXBURG
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State | ID
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Zip | 83460-0001
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Country | US
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Telephone | 208-496-9330
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Fax | 208-496-9343
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Authorized Official
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Title or Position | PCHY DIR
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Name | SHAWN ANDREASEN
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Credential | PHARMD RPH
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Telephone | 208-496-9330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | 614RP
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License Number State | ID
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