Provider Demographics
NPI:1861495160
Name:MEDICAL CENTER PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL CENTER PHARMACY INC
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:801-350-8140
Mailing Address - Street 1:1050 E SOUTH TEMPLE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1507
Mailing Address - Country:US
Mailing Address - Phone:801-350-8140
Mailing Address - Fax:801-350-4791
Practice Address - Street 1:1050 E SOUTH TEMPLE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1507
Practice Address - Country:US
Practice Address - Phone:801-350-8140
Practice Address - Fax:801-350-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT37123517033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4608583OtherNCPDP PROVIDER IDENTIFICATION NUMBER
UT841379675007Medicaid
4608583OtherNCPDP PROVIDER IDENTIFICATION NUMBER