Provider Demographics
NPI:1609012756
Name:KOEVEN, STEWART S (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:S
Last Name:KOEVEN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 BERKELEY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:89108
Mailing Address - Country:US
Mailing Address - Phone:801-487-4050
Mailing Address - Fax:
Practice Address - Street 1:1901 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-3201
Practice Address - Country:US
Practice Address - Phone:801-487-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT148212-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist