Provider Demographics
NPI:1356426753
Name:SKYLINE PHARMACY INC.
Entity type:Organization
Organization Name:SKYLINE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BLACKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-462-2434
Mailing Address - Street 1:1 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-1327
Mailing Address - Country:US
Mailing Address - Phone:435-462-2434
Mailing Address - Fax:435-462-3400
Practice Address - Street 1:1 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-1327
Practice Address - Country:US
Practice Address - Phone:435-462-2434
Practice Address - Fax:435-462-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
UT131751-1703332BP3500X, 3336C0004X, 3336H0001X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4606301OtherNABP#
UT840437031001Medicaid
UT840437031001Medicaid