Healthcare Provider Details

I. General information

NPI: 1497890099
Provider Name (Legal Business Name): HI MOUNTAIN DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 NORTH MAIN
KAMAS UT
84036
US

IV. Provider business mailing address

PO BOX 67
KAMAS UT
84036
US

V. Phone/Fax

Practice location:
  • Phone: 435-783-4466
  • Fax: 435-783-4567
Mailing address:
  • Phone: 435-783-4466
  • Fax: 435-783-4567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0285417220
License Number StateUT

VIII. Authorized Official

Name: MR. CRAIG C VAN TASSELL
Title or Position: OWNER PHARMACIST
Credential: RPH
Phone: 435-783-4466