Provider Demographics
NPI:1790500171
Name:BEAR LAKE DRUG GARDEN CITY
Entity type:Organization
Organization Name:BEAR LAKE DRUG GARDEN CITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHERYS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-589-9657
Mailing Address - Street 1:836 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1423
Mailing Address - Country:US
Mailing Address - Phone:435-294-2300
Mailing Address - Fax:
Practice Address - Street 1:288 S PARADISE PARKWAY
Practice Address - Street 2:PHARMACY
Practice Address - City:GARDEN CITY
Practice Address - State:UT
Practice Address - Zip Code:84028
Practice Address - Country:US
Practice Address - Phone:435-294-2300
Practice Address - Fax:435-990-7240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy