Provider Demographics
NPI:1275261240
Name:COLLAKU, FAZLI (PHARM D)
Entity Type:Individual
Prefix:
First Name:FAZLI
Middle Name:
Last Name:COLLAKU
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 W 2740 N
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4354
Mailing Address - Country:US
Mailing Address - Phone:801-425-1796
Mailing Address - Fax:
Practice Address - Street 1:475 E STATE RD
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2558
Practice Address - Country:US
Practice Address - Phone:801-756-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8542947-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist