Healthcare Provider Details

I. General information

NPI: 1558605816
Provider Name (Legal Business Name): DAVIS-BURKETT FOOD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 06/03/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 N STATE ST
LA VERKIN UT
84745-5124
US

IV. Provider business mailing address

495 N STATE ST
LA VERKIN UT
84745-5124
US

V. Phone/Fax

Practice location:
  • Phone: 435-635-6944
  • Fax: 435-635-1547
Mailing address:
  • Phone: 435-635-6944
  • Fax: 435-635-1547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number8383904-1703
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8383904-1703
License Number StateUT

VIII. Authorized Official

Name: MIKE SORENSON
Title or Position: PHARMACY OPERATIONS MANAGER
Credential:
Phone: 435-789-7011