Provider Demographics
NPI:1013148071
Name:SOUTH VALLEY COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH VALLEY COMPOUNDING PHARMACY LLC
Other - Org Name:SOUTH VALLEY COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHAMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BART
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:801-676-7880
Mailing Address - Street 1:3796 W 12600 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7215
Mailing Address - Country:US
Mailing Address - Phone:801-676-7880
Mailing Address - Fax:801-676-7883
Practice Address - Street 1:3796 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7215
Practice Address - Country:US
Practice Address - Phone:801-676-7880
Practice Address - Fax:801-676-7883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT9436474-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1013148071Medicaid
2121956OtherPK