Provider Demographics
NPI:1114597853
Name:SPANISH VALLEY CLINIC PHARMACY
Entity Type:Organization
Organization Name:SPANISH VALLEY CLINIC PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOTHWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:435-587-2116
Mailing Address - Street 1:380 W 100 N
Mailing Address - Street 2:PO BOX 308
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535
Mailing Address - Country:US
Mailing Address - Phone:435-587-2116
Mailing Address - Fax:435-587-3329
Practice Address - Street 1:5555 OLD AIRPORT RD.
Practice Address - Street 2:
Practice Address - City:SPANISH VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84532
Practice Address - Country:US
Practice Address - Phone:435-587-1181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN HEALTH SERVICE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-25
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy