Provider Demographics
NPI:1063651669
Name:UINTAH BASIN MEDICAL CENTER
Entity Type:Organization
Organization Name:UINTAH BASIN MEDICAL CENTER
Other - Org Name:DUCHESNE VALLEY MEDICAL CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-722-6123
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:50 EAST 200 SOUTH
Mailing Address - City:DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84021-0905
Mailing Address - Country:US
Mailing Address - Phone:435-738-5403
Mailing Address - Fax:435-738-5405
Practice Address - Street 1:50 EAST 200 SOUTH
Practice Address - Street 2:
Practice Address - City:DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84021
Practice Address - Country:US
Practice Address - Phone:435-738-5403
Practice Address - Fax:435-738-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
UT7263753-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4611249OtherNCPDP PROVIDER IDENTIFICATION NUMBER