Provider Demographics
NPI:1083963755
Name:BATES, BROCK T
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:T
Last Name:BATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 N FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2725
Mailing Address - Country:US
Mailing Address - Phone:801-546-6352
Mailing Address - Fax:
Practice Address - Street 1:255 36TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7120
Practice Address - Country:US
Practice Address - Phone:801-689-1358
Practice Address - Fax:801-689-1361
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6299233-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist