Provider Demographics
NPI:1861587081
Name:BEAR LAKE COMMUNITY HEALTH CENTER PHARMACY
Entity type:Organization
Organization Name:BEAR LAKE COMMUNITY HEALTH CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:D.J.
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:435-946-3660
Mailing Address - Street 1:325 WEST LOGAN HWY.
Mailing Address - Street 2:P. O. BOX 328
Mailing Address - City:GARDEN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84028
Mailing Address - Country:US
Mailing Address - Phone:435-946-2770
Mailing Address - Fax:435-946-2781
Practice Address - Street 1:325 WEST LOGAN HWY.
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:UT
Practice Address - Zip Code:84028
Practice Address - Country:US
Practice Address - Phone:435-946-2770
Practice Address - Fax:435-946-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health