Healthcare Provider Details

I. General information

NPI: 1003251638
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S 200 E STE 250
SALT LAKE CITY UT
84111-3846
US

IV. Provider business mailing address

660 S 200 E SUITE 250
SALT LAKE CITY UT
84111-3835
US

V. Phone/Fax

Practice location:
  • Phone: 801-359-2256
  • Fax:
Mailing address:
  • Phone: 801-359-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number8547079-1704
License Number StateUT

VIII. Authorized Official

Name: LINDA THATCHER
Title or Position: BILLING
Credential:
Phone: 801-359-2256