MEDICARE: DAVIS-BURKETT FOOD CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	5790736-1703	UT
2	333600000X	Pharmacy	5790736-1703	UT

General Provider Information

NPI Number	:	1255324554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS-BURKETT FOOD CORP

Provider Business Mailing Address
First Line	:	575 W MAIN ST
Second Line	:
City	:	VERNAL
State	:	UT
Zip	:	84078-2405
Country	:	US
Telephone Number	:	435-789-7011
Fax Number	:	435-781-4804

Provider Business Practice Location Address
First Line	:	575 W MAIN ST
Second Line	:
City	:	VERNAL
State	:	UT
Zip	:	84078-2405
Country	:	US
Telephone Number	:	435-789-7011
Fax Number	:	435-781-4804

Authorized Official
Title or Position	:	PHARMACY OPERATIONS MANAGER
Name	:	MIKE SORENSON
Credential	:	PHARMD
Telephone Number	:	435-789-7011

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	06/03/2021

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Directions to “DAVIS-BURKETT FOOD CORP ” Practice Location

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