Provider Demographics
NPI:1235918962
Name:MOAB VALLEY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:MOAB VALLEY HEALTHCARE, INC.
Other - Org Name:PORTAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOJCIESZEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-719-3558
Mailing Address - Street 1:480 W WILLIAMS WAY
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 W WILLIAMS WAY
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532
Practice Address - Country:US
Practice Address - Phone:435-719-3650
Practice Address - Fax:435-719-5556
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOAB VALLEY HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-22
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy