Provider Demographics
NPI:1578652160
Name:UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH
Other - Org Name:SOUTH JORDAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY BUSINESS OPERATIONS MANAGE
Authorized Official - Prefix:
Authorized Official - First Name:KELLEE
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:801-587-6334
Mailing Address - Street 1:PO BOX 841208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-1208
Mailing Address - Country:US
Mailing Address - Phone:801-587-6334
Mailing Address - Fax:801-587-2996
Practice Address - Street 1:5126 W DAYBREAK PKWY
Practice Address - Street 2:ROOM 101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-5994
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:2006-10-12
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT813974517033336C0003X, 3336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4609561OtherNCPDP
2100755OtherPK
0345070016Medicare NSC