Healthcare Provider Details

I. General information

NPI: 1245161058
Provider Name (Legal Business Name): CONFEDERATED TRIBES OF THE GOSHUTE RESERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E WENDOVER BLVD
WENDOVER UT
84083
US

IV. Provider business mailing address

1100 E WENDOVER BLVD
WENDOVER UT
84083
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 TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: THOMAS JAMES STETSER
Title or Position: PHARMACY DIRECTOR
Credential: PHARM.D.
Phone: 801-359-2256