Provider Demographics
NPI:1376568188
Name:WAYNE COMMUNITY HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:WAYNE COMMUNITY HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DONAVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-425-3744
Mailing Address - Street 1:128 SOUTH 300 WEST
Mailing Address - Street 2:P.O. BOX 303
Mailing Address - City:BICKNELL
Mailing Address - State:UT
Mailing Address - Zip Code:84715-0303
Mailing Address - Country:US
Mailing Address - Phone:435-425-3744
Mailing Address - Fax:435-425-1139
Practice Address - Street 1:128 SOUTH 300 WEST
Practice Address - Street 2:
Practice Address - City:BICKNELL
Practice Address - State:UT
Practice Address - Zip Code:84715-0303
Practice Address - Country:US
Practice Address - Phone:435-425-3744
Practice Address - Fax:435-425-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4855620-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========022Medicaid
UT=========022Medicaid