Provider Demographics
NPI:1366552267
Name:CENTRAL VALLEY MEDICAL CENTER PHARMACY
Entity type:Organization
Organization Name:CENTRAL VALLEY MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:BRECKENRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-623-3040
Mailing Address - Street 1:48 W 1500 N
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-8900
Mailing Address - Country:US
Mailing Address - Phone:435-623-3040
Mailing Address - Fax:
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT48338381704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========070Medicaid