Provider Demographics
NPI:1649720723
Name:CARBON MEDICAL SERVICE ASSOCIATION INCORPORATED
Entity type:Organization
Organization Name:CARBON MEDICAL SERVICE ASSOCIATION INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-299-9165
Mailing Address - Street 1:125 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HELPER
Mailing Address - State:UT
Mailing Address - Zip Code:84526-1535
Mailing Address - Country:US
Mailing Address - Phone:435-472-3208
Mailing Address - Fax:
Practice Address - Street 1:125 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HELPER
Practice Address - State:UT
Practice Address - Zip Code:84526-1535
Practice Address - Country:US
Practice Address - Phone:435-299-9165
Practice Address - Fax:425-908-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
UT10190995-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166969OtherPK
UT1649720723Medicaid