1972870517 NPI number — STATE OF UTAH

Table of content: (NPI 1972870517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972870517 NPI number — STATE OF UTAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF UTAH
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:
CHS USCF 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:
1972870517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1480 N 8000 W
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:
84116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-522-7142
Provider Business Mailing Address Fax Number:
385-465-6186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14425 BITTERBRUSH LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-9501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-576-7116
Provider Business Practice Location Address Fax Number:
801-576-7059
Provider Enumeration Date:
11/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KENYON
Authorized Official First Name:
DEANA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CHS DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
801-522-7142

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  1228741704 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4612152 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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