Basic Information
Provider Information | |||||||||
NPI: | 1083886865 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAR LAKE COMMUNITY HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CACHE VALLEY COMMUNITY HEALTH CENTER PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 517 W 100 N STE 210 | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | UT | ||||||||
PostalCode: | 843329826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357556061 | ||||||||
FaxNumber: | 4357558436 | ||||||||
Practice Location | |||||||||
Address1: | 1515 N 400 E | ||||||||
Address2: | SUITE 104 | ||||||||
City: | NORTH LOGAN | ||||||||
State: | UT | ||||||||
PostalCode: | 843417561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357558424 | ||||||||
FaxNumber: | 4357558436 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2008 | ||||||||
LastUpdateDate: | 06/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARCIA | ||||||||
AuthorizedOfficialFirstName: | JORGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4357556061 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0002X | 7712046-1703 | UT | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 4610982 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |