Provider Demographics
NPI:1043628928
Name:BLACK, WILLIAM (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 S 500 E APT 217
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4024
Mailing Address - Country:US
Mailing Address - Phone:270-349-3009
Mailing Address - Fax:
Practice Address - Street 1:343 S 500 E APT 217
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4024
Practice Address - Country:US
Practice Address - Phone:270-349-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9048650-1701183500000X
KY017073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist