Provider Demographics
NPI:1295829976
Name:TERRACE PHARMACY
Entity Type:Organization
Organization Name:TERRACE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:V
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-479-9645
Mailing Address - Street 1:5167 ADAMS AVE
Mailing Address - Street 2:#B
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4522
Mailing Address - Country:US
Mailing Address - Phone:801-479-9645
Mailing Address - Fax:801-475-6404
Practice Address - Street 1:5167 ADAMS AVE
Practice Address - Street 2:#B
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4522
Practice Address - Country:US
Practice Address - Phone:801-479-9645
Practice Address - Fax:801-475-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7572230-17033336C0003X
UT7872230-89133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528962785009Medicaid
UT528962785009Medicaid