Provider Demographics
NPI:1497194013
Name:IDAHO STATE UNIVERSITY
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:ISU BENGAL PHARMACY POCATELLO
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RIKKI
Authorized Official - Middle Name:K
Authorized Official - Last Name:TRUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-282-3407
Mailing Address - Street 1:990 S 8TH AVE
Mailing Address - Street 2:STOP 8158
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-3407
Mailing Address - Fax:
Practice Address - Street 1:990 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4982
Practice Address - Country:US
Practice Address - Phone:208-282-3407
Practice Address - Fax:208-282-6150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
ID21626RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1497194013Medicaid