Provider Demographics
NPI:1992726962
Name:BYU ID STUDENT HLTH CNTR PCHY
Entity type:Organization
Organization Name:BYU ID STUDENT HLTH CNTR PCHY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PCHY DIR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREASEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD RPH
Authorized Official - Phone:208-496-9330
Mailing Address - Street 1:179 STUDENT HLTH CTR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83460-0001
Mailing Address - Country:US
Mailing Address - Phone:208-496-9330
Mailing Address - Fax:208-496-9343
Practice Address - Street 1:179 STUDENT HLTH CTR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83460-0001
Practice Address - Country:US
Practice Address - Phone:208-496-9330
Practice Address - Fax:208-496-9343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
ID614RP3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020561OtherPK