# IDAHO STATE UNIVERSITY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Idaho State University Student Health Center Pharmacy
- **Organization subpart:** No

## Provider details

- **NPI number:** 1730351081
- **Authorized official:** GINA DAVIS (PHARMACY MANAGER)
- **Authorized official phone:** (208) 282-3407

## Contact information

- **Practice address:** 990 SOUTH 8TH, POCATELLO, ID 83209
- **Practice address phone:** (208) 282-3407
- **Mailing address:** 921 S 8TH AVE STOP 8311, POCATELLO, ID 83209-0002
- **Mailing address phone:** (208) 282-3407

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0002X | Clinic Pharmacy | 349CP | ID | Yes |

## Other

- **Enumeration date:** 03/27/2008
- **Last updated:** 02/03/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1307974 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |