Provider Demographics
NPI:1881017598
Name:UTAH STATE UNIVERSITY HEALTH CENTER
Entity Type:Organization
Organization Name:UTAH STATE UNIVERSITY HEALTH CENTER
Other - Org Name:HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-797-1660
Mailing Address - Street 1:9100 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-9100
Mailing Address - Country:US
Mailing Address - Phone:435-797-1660
Mailing Address - Fax:435-797-3585
Practice Address - Street 1:850 E 1200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-9100
Practice Address - Country:US
Practice Address - Phone:435-797-1660
Practice Address - Fax:435-797-3585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT122899-1703261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service