Provider Demographics
NPI:1003948670
Name:SWENSON, MARK ALAN (R,PH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SWENSON
Suffix:
Gender:M
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ANN ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-3417
Mailing Address - Country:US
Mailing Address - Phone:801-255-3101
Mailing Address - Fax:
Practice Address - Street 1:10130 S STATE ST
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4118
Practice Address - Country:US
Practice Address - Phone:801-255-3101
Practice Address - Fax:801-255-3101
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT179298-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist