MEDICARE: BEAR LAKE COMMUNITY HEALTH CENTER PHARMACY

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	261QC1500X	Community Health Clinic/Center		UT

General Provider Information

NPI Number	:	1861587081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAR LAKE COMMUNITY HEALTH CENTER PHARMACY

Provider Business Mailing Address
First Line	:	325 WEST LOGAN HWY.
Second Line	:	P. O. BOX 328
City	:	GARDEN CITY
State	:	UT
Zip	:	84028
Country	:	US
Telephone Number	:	435-946-2770
Fax Number	:	435-946-2781

Provider Business Practice Location Address
First Line	:	325 WEST LOGAN HWY.
Second Line	:
City	:	GARDEN CITY
State	:	UT
Zip	:	84028
Country	:	US
Telephone Number	:	435-946-2770
Fax Number	:	435-946-2781

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	D.J. BALLINGHAM
Credential	:	PA-C
Telephone Number	:	435-946-3660

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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