Provider Demographics
NPI:1275838575
Name:UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH
Other - Org Name:SOUTH JORDAN DAYBREAK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SRV. DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6325
Mailing Address - Street 1:4696 DAYBREAK RIM WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5129
Mailing Address - Country:US
Mailing Address - Phone:801-213-4550
Mailing Address - Fax:801-213-4555
Practice Address - Street 1:4696 DAYBREAK RIM WAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5129
Practice Address - Country:US
Practice Address - Phone:801-213-4550
Practice Address - Fax:801-213-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7824017-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4611922OtherNCPDP PROVIDER IDENTIFICATION NUMBER