Provider Demographics
NPI:1598776080
Name:EJVF LLC
Entity Type:Organization
Organization Name:EJVF LLC
Other - Org Name:BULLOCHS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-586-9651
Mailing Address - Street 1:91 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-2648
Mailing Address - Country:US
Mailing Address - Phone:435-586-9651
Mailing Address - Fax:435-586-3473
Practice Address - Street 1:91 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-2648
Practice Address - Country:US
Practice Address - Phone:435-586-9651
Practice Address - Fax:435-586-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT314272-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1402009Medicaid
2106943OtherPK
4601298OtherOTHER ID NUMBER-COMMERCIAL NUMBER
UT=========009Medicaid