Healthcare Provider Details

I. General information

NPI: 1053575175
Provider Name (Legal Business Name): IHC HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N 200 E
LOGAN UT
84321-4038
US

IV. Provider business mailing address

PO BOX 30013
SALT LAKE CITY UT
84130-0013
US

V. Phone/Fax

Practice location:
  • Phone: 435-713-2770
  • Fax: 435-713-2787
Mailing address:
  • Phone: 435-713-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number70157141703
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2100988
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier1053575175
Identifier TypeMEDICAID
Identifier StateID
Identifier Issuer
# 3
Identifier1053575175
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: NANNETTE BERENSEN
Title or Position: VICE PRESIDENT OF CLINICAL SYSTEMS
Credential:
Phone: 801-284-1005