Provider Demographics
NPI:1679546709
Name:PAUL REAM ENTERPRISES
Entity Type:Organization
Organization Name:PAUL REAM ENTERPRISES
Other - Org Name:REAMS FAMILY FOODS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NAKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-356-3784
Mailing Address - Street 1:2250 N UNIVERSITY PKWY
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1500
Mailing Address - Country:US
Mailing Address - Phone:801-356-3784
Mailing Address - Fax:801-356-0559
Practice Address - Street 1:2250 N UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1500
Practice Address - Country:US
Practice Address - Phone:801-356-3784
Practice Address - Fax:801-356-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT60307971703333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4610374OtherNCPDP
UT=========001Medicaid