1790500171 NPI number — BEAR LAKE DRUG GARDEN CITY

Table of content: (NPI 1790500171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790500171 NPI number — BEAR LAKE DRUG GARDEN CITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAR LAKE DRUG GARDEN CITY
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:
1790500171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
836 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTPELIER
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83254-1423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-294-2300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
288 S PARADISE PARKWAY
Provider Second Line Business Practice Location Address:
PHARMACY
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-294-2300
Provider Business Practice Location Address Fax Number:
435-990-7240
Provider Enumeration Date:
11/20/2024

Additional Information

Authorized Official

Authorized Official Last Name:
HUMPHERYS
Authorized Official First Name:
CASEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PHARMACIST IN CHARGE
Authorized Official Telephone Number:
208-589-9657

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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