Provider Demographics
NPI:1841647179
Name:BLUE EYES OF UTAH LLC
Entity type:Organization
Organization Name:BLUE EYES OF UTAH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRESSERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-685-5041
Mailing Address - Street 1:205 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:157 E RIVERSIDE DR
Practice Address - Street 2:SUITE 3E
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6886
Practice Address - Country:US
Practice Address - Phone:435-359-1805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9777440-17043336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy