Provider Demographics
NPI:1194831552
Name:MIDTOWN COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:MIDTOWN COMMUNITY HEALTH CENTER INC
Other - Org Name:MIDTOWN COMMUNITY HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSPHARM
Authorized Official - Phone:801-334-1321
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-395-8200
Mailing Address - Fax:801-436-1015
Practice Address - Street 1:2240 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1511
Practice Address - Country:US
Practice Address - Phone:801-395-8200
Practice Address - Fax:801-436-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT618917517043336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100848OtherPK
UT=========001Medicaid