Provider Demographics
NPI:1861815110
Name:MOUNTAINLANDS FAMILY PHARMACY - WASATCH
Entity Type:Organization
Organization Name:MOUNTAINLANDS FAMILY PHARMACY - WASATCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-429-2000
Mailing Address - Street 1:589 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5056
Mailing Address - Country:US
Mailing Address - Phone:801-429-2020
Mailing Address - Fax:
Practice Address - Street 1:750 N 200 W
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-3539
Practice Address - Country:US
Practice Address - Phone:801-429-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAINLANDS COMMINITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-22
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy