Provider Demographics
NPI:1568720704
Name:AXIOM SPECIALTY RX
Entity Type:Organization
Organization Name:AXIOM SPECIALTY RX
Other - Org Name:AXIOM SPECIALTY RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-727-8106
Mailing Address - Street 1:912 BAXTER DR STE 130
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5876
Mailing Address - Country:US
Mailing Address - Phone:801-727-8106
Mailing Address - Fax:801-495-5923
Practice Address - Street 1:912 BAXTER DR STE 130
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5876
Practice Address - Country:US
Practice Address - Phone:801-727-8106
Practice Address - Fax:801-495-5923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT778953217043336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4612203OtherNCPDP PROVIDER IDENTIFICATION NUMBER