Provider Demographics
NPI:1962894758
Name:PREMIER CARE PHARMACY
Entity type:Organization
Organization Name:PREMIER CARE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NAKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-607-2138
Mailing Address - Street 1:863 N 980 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-7710
Mailing Address - Country:US
Mailing Address - Phone:801-607-2138
Mailing Address - Fax:801-225-2388
Practice Address - Street 1:863 N 980 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-7710
Practice Address - Country:US
Practice Address - Phone:801-607-2138
Practice Address - Fax:801-225-2388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336L0003X
UT929972289131835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Multi-Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1962894758Medicaid
UT1962894758OtherSTATE LICENSE