Organization
WADE R POULSON
Active
Other names
Scotch Pine Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
WADE POULSON (OWNER)
(801) 389-0267
Entity
Organization
Contact information
Practice address
1322 N SCOTCH PINE DR, DUCHESNE, UT 84021-0464
(435) 738-0155
(435) 738-0153
Mailing address
PO BOX 464, DUCHESNE, UT 84021-0464
(801) 389-0267
(435) 738-0153
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
—
—
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4611833
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
05/25/2010
Last updated
11/12/2010
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