Provider Demographics
NPI:1083393284
Name:IDAHO STATE UNIVERSITY
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:ISU BENGAL PHARMACY MCCAMMON
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICS DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-373-1743
Mailing Address - Street 1:990 S 8TH AVE STOP 8158
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4982
Mailing Address - Country:US
Mailing Address - Phone:208-282-3407
Mailing Address - Fax:
Practice Address - Street 1:206 CENTER ST.
Practice Address - Street 2:
Practice Address - City:MCCAMMON
Practice Address - State:ID
Practice Address - Zip Code:83250
Practice Address - Country:US
Practice Address - Phone:208-282-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-14
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy