Provider Demographics
NPI:1396827077
Name:DIVERSIFIED PROFESSIONAL COMPANY
Entity Type:Organization
Organization Name:DIVERSIFIED PROFESSIONAL COMPANY
Other - Org Name:PETERSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-479-4030
Mailing Address - Street 1:PO BOX 150010
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0010
Mailing Address - Country:US
Mailing Address - Phone:801-479-4030
Mailing Address - Fax:801-475-7051
Practice Address - Street 1:4650 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-479-4030
Practice Address - Fax:801-475-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT132801-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870218488006Medicaid
UT0437970001Medicare NSC