Basic Information
Provider Information | |||||||||
NPI: | 1568732501 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEAR LAKE COMMUNITY HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EVANSTON 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: | 4359949826 | ||||||||
Practice Location | |||||||||
Address1: | 75 YELLOW CREEK RD # S-102 | ||||||||
Address2: |   | ||||||||
City: | EVANSTON | ||||||||
State: | WY | ||||||||
PostalCode: | 829305235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077898291 | ||||||||
FaxNumber: | 3077892105 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2012 | ||||||||
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 | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0002X | R10072 | WY | Y |   | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 5204398 | 01 |   | NCPDP | OTHER | 2132905 | 01 |   | PK | OTHER |