Provider Demographics
NPI:1417022864
Name:UINTAH BASIN MEDICAL CENTER INC
Entity Type:Organization
Organization Name:UINTAH BASIN MEDICAL CENTER INC
Other - Org Name:UINTAH BASIN MEDICAL CENTER OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-722-6162
Mailing Address - Street 1:250 W 300 N
Mailing Address - Street 2:(75-2)
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2336
Mailing Address - Country:US
Mailing Address - Phone:435-722-6123
Mailing Address - Fax:
Practice Address - Street 1:250 W 300 N
Practice Address - Street 2:(75-2)
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-6123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UINTAH BASIN MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-21
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT4788706-17033336C0002X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========151Medicaid