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Organization
STATE OF IDAHO
Active
Organization
STATE OF IDAHO
Active
Other names
State Hospital South Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TRACEY G. SESSIONS (ADMINISTRATIVE DIRECTOR)
(208) 785-8406
Entity
Organization
Contact information
Practice address
700 EAST ALICE STREET, BLACKFOOT, ID 83221
(208) 785-1200
(208) 785-8424
Mailing address
700 EAST ALICE STREET, PO BOX 400, BLACKFOOT, ID 83221
(208) 785-1200
(208) 785-8424
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
462HP
ID
3336L0003X
Long Term Care Pharmacy
462HP
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002825500
—
ID
05
—
002835700
—
ID
01
—
1302772
NABP & NCPDP
ID
Enumeration date
12/13/2006
Last updated
06/16/2018
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