1396852000 NPI number — IHC HEALTH SERVICES INC

Table of content: JUSTIN K LEE (NPI 1730440017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396852000 NPI number — IHC HEALTH SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IHC HEALTH SERVICES 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:
INTERMOUNTAIN HOMECARE PHARMACY
Provider Other Organization Name Type Code:
3
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:
1396852000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84130-0180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
385-887-7351
Provider Business Mailing Address Fax Number:
801-442-0709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11520 S REDWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84095-7805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
385-887-7351
Provider Business Practice Location Address Fax Number:
801-442-0709
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACEY
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
385-887-6275

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1396852000 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2100193 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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