=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821182957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONGER DRUG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 07/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 790 E MAIN ST
-----------------------------------------------------
City | HYRUM
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84319-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-245-6422
-----------------------------------------------------
Fax | 435-245-5306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 790 E MAIN ST
-----------------------------------------------------
City | HYRUM
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84319-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-245-6422
-----------------------------------------------------
Fax | 435-245-5306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST OWNER
-----------------------------------------------------
Name | MICHAEL CONGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-245-6422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 55732481703
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------