Provider Demographics
NPI:1174638118
Name:NIELSON FAMILY PHARMACY CORP
Entity Type:Organization
Organization Name:NIELSON FAMILY PHARMACY CORP
Other - Org Name:THE MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-278-2101
Mailing Address - Street 1:2036 E 6200 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2036 E 6200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2268
Practice Address - Country:US
Practice Address - Phone:801-278-2101
Practice Address - Fax:801-278-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT55239031703333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4607947OtherOTHER ID NUMBER-COMMERCIAL NUMBER
UT=========001Medicaid