Provider Demographics
NPI:1447385893
Name:IDAHO RX INC
Entity type:Organization
Organization Name:IDAHO RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-745-6831
Mailing Address - Street 1:139 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1417
Mailing Address - Country:US
Mailing Address - Phone:208-745-6831
Mailing Address - Fax:208-745-6161
Practice Address - Street 1:139 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1417
Practice Address - Country:US
Practice Address - Phone:208-745-6831
Practice Address - Fax:208-745-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID2171RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807007100Medicaid
2124041OtherPK
ID807007100Medicaid