NPIMap

Organization Active NPI

Idaho State University

  • Community/Retail Pharmacy
  • Pocatello, ID
National Provider Identifier
1497194013
Registry record updated Apr 4, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
IDAHO STATE UNIVERSITY
Practice address
990 S 8TH Ave
Pocatello, ID 83201-4982
Phone
(208) 282-3407
Fax
(208) 282-6150
NPI assigned
Jun 17, 2013
Last updated
Apr 4, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2022

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

Authorized official

Name
Rikki K Trussel
Title
Pharmacy Manager
Phone
(208) 282-3407

Specialties & licenses 1

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

Addresses

Primary practice location

990 S 8TH Ave
Pocatello, ID 83201-4982

Mailing address

990 S 8TH Ave
Stop 8158
Pocatello, ID 83209-0001
Phone (208) 282-3407

Other identifiers 1

IdentifierTypeStateIssuer
1497194013MedicaidID

Other names 1

  • ISU Bengal Pharmacy Pocatello 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
Practice locations: Arco, ID; Challis, ID; Chubbuck, ID; McCammon, ID; Pocatello, ID

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

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 University3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Locations

990 Cesar Chavez
Pocatello, ID 83209
Phone (208) 282-2330

NPI Registry JSON

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

{
    "created_epoch": "1371427200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649030400000",
    "number": "1497194013",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "990 S 8TH AVE",
            "address_2": "STOP 8158",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832090001",
            "telephone_number": "208-282-3407"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "990 S 8TH AVE",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832014982",
            "telephone_number": "208-282-3407",
            "fax_number": "208-282-6150"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO STATE UNIVERSITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-06-17",
        "last_updated": "2022-04-04",
        "certification_date": "2022-04-04",
        "status": "A",
        "authorized_official_last_name": "TRUSSEL",
        "authorized_official_first_name": "RIKKI",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "PHARMACY MANAGER",
        "authorized_official_telephone_number": "208-282-3407"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1497194013",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ISU Bengal Pharmacy Pocatello",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Pocatello, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 4, 2022; 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.