Provider Demographics
NPI:1902825854
Name:CENTRAL VALLEY MEDICAL CENTER
Entity Type:Organization
Organization Name:CENTRAL VALLEY MEDICAL CENTER
Other - Org Name:CENTRAL VALLEY COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-623-3000
Mailing Address - Street 1:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-0412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:435-623-3704
Practice Address - Street 1:152 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-5520
Practice Address - Country:US
Practice Address - Phone:435-623-3700
Practice Address - Fax:435-623-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT623308617033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100851OtherPK
UT=========003Medicaid