Provider Demographics
NPI:1073548699
Name:COMMUNTIY PHARMACY
Entity Type:Organization
Organization Name:COMMUNTIY PHARMACY
Other - Org Name:COMMUNITY PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REED
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:801-270-0600
Mailing Address - Street 1:1220 E 3900 S
Mailing Address - Street 2:STE 1H
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1377
Mailing Address - Country:US
Mailing Address - Phone:801-270-0600
Mailing Address - Fax:801-270-0605
Practice Address - Street 1:1220 E 3900 S
Practice Address - Street 2:STE 1H
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1377
Practice Address - Country:US
Practice Address - Phone:801-270-0600
Practice Address - Fax:801-270-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
UT36490317033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4607620OtherNCPDP PROVIDER IDENTIFICATION NUMBER
UT=========007Medicaid
4607620OtherNCPDP PROVIDER IDENTIFICATION NUMBER