Provider Demographics
NPI:1124579313
Name:MAZZA, ANTHONY MATTHEW (RPH)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MATTHEW
Last Name:MAZZA
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 1:1566 34TH ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1366
Mailing Address - Country:US
Mailing Address - Phone:801-627-8573
Mailing Address - Fax:
Practice Address - Street 1:2353 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUNSET
Practice Address - State:UT
Practice Address - Zip Code:84015-2454
Practice Address - Country:US
Practice Address - Phone:801-825-2262
Practice Address - Fax:801-773-3989
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-22
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5039647-1701183500000X
WY3916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist