MEDICARE: EJVF LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	314272-1703	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2106943	OTHER		PK

General Provider Information

NPI Number	:	1598776080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EJVF LLC

Provider Business Mailing Address
First Line	:	91 N MAIN ST
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-2648
Country	:	US
Telephone Number	:	435-586-9651
Fax Number	:	435-586-3473

Provider Business Practice Location Address
First Line	:	91 N MAIN ST
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-2648
Country	:	US
Telephone Number	:	435-586-9651
Fax Number	:	435-586-3473

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT VICKERS
Credential	:
Telephone Number	:	435-586-9651

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	06/14/2022

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Directions to “EJVF LLC ” Practice Location

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