Provider Demographics
NPI:1649697244
Name:MT NEBO THRIFT CORP
Entity type:Organization
Organization Name:MT NEBO THRIFT CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RX SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:MEASOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-465-2347
Mailing Address - Street 1:965 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-1003
Mailing Address - Country:US
Mailing Address - Phone:435-623-2183
Mailing Address - Fax:435-623-4237
Practice Address - Street 1:965 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648
Practice Address - Country:US
Practice Address - Phone:435-623-2183
Practice Address - Fax:435-623-4237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT8963467-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1649697244Medicaid
2145208OtherPK