Provider Demographics
NPI:1467584300
Name:BRIGHAM YOUNG UNIVERSITY
Entity Type:Organization
Organization Name:BRIGHAM YOUNG UNIVERSITY
Other - Org Name:BRIGHAM YOUNG UNIVERSITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:AVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-422-9701
Mailing Address - Street 1:1750 N WYMOUNT TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-8600
Mailing Address - Country:US
Mailing Address - Phone:801-422-5171
Mailing Address - Fax:801-422-0812
Practice Address - Street 1:1750 N WYMOUNT TERRACE DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-8600
Practice Address - Country:US
Practice Address - Phone:801-422-5171
Practice Address - Fax:801-422-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT35943017033336C0002X
UT359430-17033336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4601971OtherNCPDP PROVIDER IDENTIFICATION NUMBER