Basic Information
| Provider Information | |||||||||
| NPI: | 1346986908 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTHCARE PHARMACY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 25 N 100 E STE 102 | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847707369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4359862565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2276 E RIVERSIDE DR. | ||||||||
| Address2: | |||||||||
| City: | ST. GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847908479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4359862565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2022 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 4359862565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST UTAH COMMUNITY HEALTH CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 1891237640 | 01 | NPPES | OTHER |