Healthcare Provider Details

I. General information

NPI: 1164435129
Provider Name (Legal Business Name): UTAH STATE DEVELOPMENTAL CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 N 900 E
AMERICAN FORK UT
84003-9183
US

IV. Provider business mailing address

895 N 900 E
AMERICAN FORK UT
84003-9183
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-4036
  • Fax: 801-763-4073
Mailing address:
  • Phone: 801-763-4036
  • Fax: 801-763-4073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number122434-1704
License Number StateUT

VIII. Authorized Official

Name: MR. FRANK WHITNEY
Title or Position: PHARMACY DIRECTOR
Credential: RP
Phone: 801-763-4160