1215663802 NPI number — COMMUNITY COUNCIL OF IDAHO, INC

Table of content: (NPI 1215663802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215663802 NPI number — COMMUNITY COUNCIL OF IDAHO, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY COUNCIL OF IDAHO, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215663802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 ALAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-470-7979
Provider Business Mailing Address Fax Number:
888-626-5817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1491 PARKWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKFOOT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83221-1667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-435-2379
Provider Business Practice Location Address Fax Number:
833-726-1877
Provider Enumeration Date:
07/27/2022

Additional Information

Authorized Official

Authorized Official Last Name:
COULSON
Authorized Official First Name:
TROY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY DIRECTOR
Authorized Official Telephone Number:
208-470-7979

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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