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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