Provider Demographics
NPI:1861780439
Name:BIRCH PHARMACEUTICAL LLC
Entity type:Organization
Organization Name:BIRCH PHARMACEUTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-882-7775
Mailing Address - Street 1:4776 N AUTUMNCOVE
Mailing Address - Street 2:
Mailing Address - City:ERDA
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9372
Mailing Address - Country:US
Mailing Address - Phone:435-882-8880
Mailing Address - Fax:435-882-8881
Practice Address - Street 1:6727 N. HWY 36
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-882-8880
Practice Address - Fax:435-882-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8055593-1703333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4612049OtherNCPDP PROVIDER IDENTIFICATION NUMBER
UT6713400001OtherMEDICARE
UT1861780439Medicaid