Healthcare Provider Details

I. General information

NPI: 1376568188
Provider Name (Legal Business Name): WAYNE COMMUNITY HEALTH CENTER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 SOUTH 300 WEST
BICKNELL UT
84715-0303
US

IV. Provider business mailing address

128 SOUTH 300 WEST P.O. BOX 303
BICKNELL UT
84715-0303
US

V. Phone/Fax

Practice location:
  • Phone: 435-425-3744
  • Fax: 435-425-1139
Mailing address:
  • Phone: 435-425-3744
  • Fax: 435-425-1139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number4855620-1703
License Number StateUT

VIII. Authorized Official

Name: DONAVAN SMITH
Title or Position: PHARMACIST
Credential: RPH.
Phone: 435-425-3744