Idaho State University
Organization Active NPI Community/Retail Pharmacy · Arco, ID
NPI 1992808059 · NPPES record last updated Apr 5, 2022
Key facts
- NPI
- 1992808059
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- Legal business name
- IDAHO STATE UNIVERSITY
- Practice address
- 551 Highland Dr
Arco, ID 83213-5003 - Phone
- (208) 527-8201
- Fax
- (208) 527-8273
- NPI assigned
- Sep 6, 2006
- Organization subpart
- No
Authorized official
- Name
- Rikki K Trussel
- Title
- Pharmacy Manager
- Phone
- (208) 282-3407
Other NPIs on the same Medicare enrollment 4
Corporate family (same tax ID) 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Tax ID family
- Idaho State University
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | Yes |
Addresses
Primary practice location
551 Highland Dr
Arco, ID 83213-5003
Mailing address
990 S 8TH Ave Stop 8158
Pocatello, ID 83209-0001
Phone (208) 282-3407
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1992808059 | Medicaid | ID |
Other names
- ISU Bengal Pharmacy Arco
Other providers in Arco, ID
- Channing Way Dental Dba Lost Rivers Dental
- CW All Services
- Eagle Rock Dental Care Arco PLLC
- Jeffrey C Haskell X
- Jerica Hemsley
- Hal J Jardine
- Lost River Emt
- Lost Rivers District Hospital
- Lost Rivers District Hospital
- Lost Rivers District Hospital
All providers in Arco, ID · Community/Retail Pharmacy in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 5, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.