Provider Demographics
NPI:1902839715
Name:SPENCE'S PRESCRIPTION PHARMACY INC
Entity Type:Organization
Organization Name:SPENCE'S PRESCRIPTION PHARMACY INC
Other - Org Name:SPENCE'S NORTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:STAKEBAKE
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:435-753-8500
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-753-8500
Mailing Address - Fax:435-753-3040
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-753-8500
Practice Address - Fax:435-753-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12598517033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870343085009Medicaid