Provider Demographics
NPI:1467549667
Name:IHC HEALTH SERVICES INC
Entity Type:Organization
Organization Name:IHC HEALTH SERVICES INC
Other - Org Name:MANTI PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL SYSTEMS
Authorized Official - Prefix:
Authorized Official - First Name:NANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-284-1005
Mailing Address - Street 1:PO BOX 30013
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0013
Mailing Address - Country:US
Mailing Address - Phone:435-835-4225
Mailing Address - Fax:
Practice Address - Street 1:159 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84642-1257
Practice Address - Country:US
Practice Address - Phone:435-835-4225
Practice Address - Fax:435-835-4227
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IHC HEALTH SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT613616517033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1467549667Medicaid
2100897OtherPK
UT1467549667Medicaid