Healthcare Provider Details

I. General information

NPI: 1417022864
Provider Name (Legal Business Name): UINTAH BASIN MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 300 N (75-2)
ROOSEVELT UT
84066-2336
US

IV. Provider business mailing address

250 W 300 N (75-2)
ROOSEVELT UT
84066-2336
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-6123
  • Fax:
Mailing address:
  • Phone: 435-722-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number4788706-1703
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number4788706-1703
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number4788706-1703
License Number StateUT

VIII. Authorized Official

Name: JAMES MARSHALL
Title or Position: CEO
Credential:
Phone: 435-722-6162