Provider Demographics
NPI:1750442315
Name:STATE OF IDAHO
Entity Type:Organization
Organization Name:STATE OF IDAHO
Other - Org Name:STATE HOSPITAL SOUTH PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SESSIONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-8406
Mailing Address - Street 1:700 EAST ALICE STREET
Mailing Address - Street 2:PO BOX 400
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-785-1200
Mailing Address - Fax:208-785-8424
Practice Address - Street 1:700 EAST ALICE STREET
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-1200
Practice Address - Fax:208-785-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID462HP333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002825500Medicaid
ID002835700Medicaid
ID1302772OtherNABP & NCPDP