MEDICARE: SPENCE'S PRESCRIPTION PHARMACY INC

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	3336C0003X	Community/Retail Pharmacy	1259851703	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

General Provider Information

NPI Number	:	1902839715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPENCE'S PRESCRIPTION PHARMACY INC

Provider Business Mailing Address
First Line	:	550 E 1400 N
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-753-8500
Fax Number	:	435-753-3040

Provider Business Practice Location Address
First Line	:	550 E 1400 N
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-753-8500
Fax Number	:	435-753-3040

Authorized Official
Title or Position	:	CFO
Name	:	MR. JARED STAKEBAKE
Credential	:	CPHT
Telephone Number	:	435-753-8500

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	12/08/2022

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Directions to “SPENCE'S PRESCRIPTION PHARMACY INC ” Practice Location

Language	Start Address	Practice Location

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