Healthcare Provider Details

I. General information

NPI: 1598776080
Provider Name (Legal Business Name): EJVF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 N MAIN ST
CEDAR CITY UT
84720-2648
US

IV. Provider business mailing address

91 N MAIN ST
CEDAR CITY UT
84720-2648
US

V. Phone/Fax

Practice location:
  • Phone: 435-586-9651
  • Fax: 435-586-3473
Mailing address:
  • Phone: 435-586-9651
  • Fax: 435-586-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number314272-1703
License Number StateUT

VIII. Authorized Official

Name: ROBERT VICKERS
Title or Position: PRESIDENT
Credential:
Phone: 435-586-9651