NPIMap

Organization Active NPI

Idaho State University

  • Community/Retail Pharmacy
  • McCammon, ID
National Provider Identifier
1083393284
Registry record updated Jul 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
IDAHO STATE UNIVERSITY
Practice address
208 Center St.
McCammon, ID 83250
Phone
(208) 282-6155
Fax
(208) 254-9372
NPI assigned
Jul 14, 2023
Last updated
Jul 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Cynthia Lee Rock
Title
Clinics Director of Operations
Phone
(208) 373-1743

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X NU Primary

Addresses

Primary practice location

208 Center St.
McCammon, ID 83250

Mailing address

990 S 8TH Ave Stop 8158
Pocatello, ID 83201-4982
Phone (208) 282-3407

Other names 1

  • ISU Bengal Pharmacy McCammon Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210719001703 ID Part B Supplier - Mass Immunization (Roster Biller Only) 4688683030 4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Arco, ID; Challis, ID; Chubbuck, ID; McCammon, ID; Pocatello, ID

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Idaho State University22 organizations share this tax ID, including this one

Other organizations with this tax ID 21

Organizations that report the same tax identification number in the National Provider Directory.

View all 21

Locations

609 Clinic Rd
Challis, ID 83226
Phone (208) 879-4600

206 Center St
McCammon, ID 83250

208 Center St
McCammon, ID 83250
Phone (208) 282-3407

Practitioners & affiliated clinicians

Practitioners 41

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 41

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1689292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720483200000",
    "number": "1083393284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "990 S 8TH AVE STOP 8158",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832014982",
            "telephone_number": "208-282-3407"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "208 CENTER ST.",
            "city": "MCCAMMON",
            "state": "ID",
            "postal_code": "83250",
            "telephone_number": "208-282-6155",
            "fax_number": "208-254-9372"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-07-14",
        "last_updated": "2024-07-09",
        "certification_date": "2024-07-09",
        "status": "A",
        "authorized_official_last_name": "ROCK",
        "authorized_official_first_name": "CYNTHIA",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "CLINICS DIRECTOR OF OPERATIONS",
        "authorized_official_telephone_number": "208-373-1743"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ISU Bengal Pharmacy McCammon",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "ISU Bengal Pharmacy McCammon",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in McCammon, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.