Provider Demographics
NPI:1417970419
Name:WILLIE, CHARLES R (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:WILLIE
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 1:134 W 2225 N
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2835
Mailing Address - Country:US
Mailing Address - Phone:801-768-8926
Mailing Address - Fax:
Practice Address - Street 1:5353 W 11000 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-9403
Practice Address - Country:US
Practice Address - Phone:801-756-8353
Practice Address - Fax:801-756-3525
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144363-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870309253012Medicaid
UT1003894973Medicare UPIN
UT870309253012Medicaid