Provider Demographics
NPI:1720270275
Name:WASATCH HOMELESS HEALTH CARE, INC.
Entity Type:Organization
Organization Name:WASATCH HOMELESS HEALTH CARE, INC.
Other - Org Name:FOURTH STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-364-0058
Mailing Address - Street 1:409 SOUTH 400 WEST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101
Mailing Address - Country:US
Mailing Address - Phone:801-333-8628
Mailing Address - Fax:801-433-0153
Practice Address - Street 1:409 WEST 400 SOUTH
Practice Address - Street 2:
Practice Address - City:SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84101-8410
Practice Address - Country:US
Practice Address - Phone:801-333-8628
Practice Address - Fax:801-433-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT494902017033336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4695613OtherOTHER ID NUMBER