Provider Demographics
NPI:1275292161
Name:COMMUNITY COUNCIL OF IDAHO, INC
Entity Type:Organization
Organization Name:COMMUNITY COUNCIL OF IDAHO, INC
Other - Org Name:COMMUNITY FAMILY CLINIC PHARMACY 340 B
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:COULSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-470-7979
Mailing Address - Street 1:2100 ALAN ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5801
Mailing Address - Country:US
Mailing Address - Phone:208-470-7979
Mailing Address - Fax:898-626-5817
Practice Address - Street 1:2100 ALAN ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-470-7979
Practice Address - Fax:888-626-5817
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY COUNCIL OF IDAHO, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-12-08
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy