Provider Demographics
NPI:1154640555
Name:WADE R POULSON
Entity Type:Organization
Organization Name:WADE R POULSON
Other - Org Name:SCOTCH PINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WADE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-389-0267
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84021-0464
Mailing Address - Country:US
Mailing Address - Phone:801-389-0267
Mailing Address - Fax:435-738-0153
Practice Address - Street 1:1322 N SCOTCH PINE DR
Practice Address - Street 2:
Practice Address - City:DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84021-0464
Practice Address - Country:US
Practice Address - Phone:435-738-0155
Practice Address - Fax:435-738-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4611833OtherNCPDP PROVIDER IDENTIFICATION NUMBER