Provider Demographics
NPI:1295765204
Name:KWIK STOP DRUG
Entity type:Organization
Organization Name:KWIK STOP DRUG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN VLEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-399-5866
Mailing Address - Street 1:325 36TH ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-1623
Mailing Address - Country:US
Mailing Address - Phone:801-399-5866
Mailing Address - Fax:801-621-4791
Practice Address - Street 1:325 36TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-1623
Practice Address - Country:US
Practice Address - Phone:801-399-5866
Practice Address - Fax:801-621-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT321208-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4600450OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4600450OtherNCPDP PROVIDER IDENTIFICATION NUMBER
UT=========005Medicaid
1277600001Medicare NSC