Healthcare Provider Details

I. General information

NPI: 1467584300
Provider Name (Legal Business Name): BRIGHAM YOUNG UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 N WYMOUNT TERRACE DR
PROVO UT
84604-8600
US

IV. Provider business mailing address

1750 N WYMOUNT TERRACE DR
PROVO UT
84604-8600
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-5171
  • Fax: 801-422-0812
Mailing address:
  • Phone: 801-422-5171
  • Fax: 801-422-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number3594301703
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number359430-1703
License Number StateUT

VIII. Authorized Official

Name: JAMES C AVERETT
Title or Position: DIRECTOR OF PHARMACY
Credential: RPH
Phone: 801-422-9701