Provider Demographics
NPI:1689134868
Name:GREEN RIVER MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:GREEN RIVER MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:DUNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-564-0213
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:UT
Mailing Address - Zip Code:84525-0417
Mailing Address - Country:US
Mailing Address - Phone:435-564-3434
Mailing Address - Fax:435-564-3214
Practice Address - Street 1:585 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:UT
Practice Address - Zip Code:84525
Practice Address - Country:US
Practice Address - Phone:435-564-3434
Practice Address - Fax:435-564-3214
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREEN RIVER MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11065988-1703OtherUTAH DOPL PHARMACY CLASS A LICENSE
UT11065988-8913OtherUTAH DOPL DISPENSING CONTROLLED SUBSTANCE LICENSE
UT261QF0400XMedicaid
UT261QF0400XMedicaid