Provider Demographics
NPI:1316042179
Name:BASIN FAMILY PHARMACY
Entity Type:Organization
Organization Name:BASIN FAMILY PHARMACY
Other - Org Name:BASIN FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUKE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-722-2454
Mailing Address - Street 1:245 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-3712
Mailing Address - Country:US
Mailing Address - Phone:435-722-2454
Mailing Address - Fax:435-722-4191
Practice Address - Street 1:245 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3712
Practice Address - Country:US
Practice Address - Phone:435-722-2454
Practice Address - Fax:435-722-4191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT4905987-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106870OtherPK
UT=========008Medicaid
UT=========008Medicaid