Provider Demographics
NPI:1164435129
Name:UTAH STATE DEVELOPMENTAL CENTER PHARMACY
Entity Type:Organization
Organization Name:UTAH STATE DEVELOPMENTAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:801-763-4160
Mailing Address - Street 1:895 N 900 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9183
Mailing Address - Country:US
Mailing Address - Phone:801-763-4036
Mailing Address - Fax:801-763-4073
Practice Address - Street 1:895 N 900 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-9183
Practice Address - Country:US
Practice Address - Phone:801-763-4036
Practice Address - Fax:801-763-4073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT122434-1704320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4603773OtherNCPDP
UT52820957000001OtherBLUE CROSS
UT876000545015Medicaid