Provider Demographics
NPI:1518508746
Name:BATH, CORRINE RANAE (RPH)
Entity Type:Individual
Prefix:
First Name:CORRINE
Middle Name:RANAE
Last Name:BATH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 S 4000 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-6233
Mailing Address - Country:US
Mailing Address - Phone:801-968-1896
Mailing Address - Fax:801-965-0488
Practice Address - Street 1:4643 S 4000 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-6233
Practice Address - Country:US
Practice Address - Phone:801-968-1896
Practice Address - Fax:801-965-0488
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT271020-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist