Healthcare Provider Details

I. General information

NPI: 1841540077
Provider Name (Legal Business Name): GREEN RIVER MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 WEST MAIN STREET
GREEN RIVER UT
84525
US

IV. Provider business mailing address

PO BOX 417
GREEN RIVER UT
84525-0417
US

V. Phone/Fax

Practice location:
  • Phone: 435-888-0422
  • Fax: 435-888-0860
Mailing address:
  • Phone: 435-564-3434
  • Fax: 435-564-9214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3739881704
License Number StateUT

VIII. Authorized Official

Name: RUSSELL SCOW
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 435-888-0422