Provider Demographics
NPI:1629396882
Name:MAUGHAN, KELLY W (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:W
Last Name:MAUGHAN
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 1:2400 N WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-7233
Mailing Address - Country:US
Mailing Address - Phone:801-786-7600
Mailing Address - Fax:801-786-7610
Practice Address - Street 1:2400 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7233
Practice Address - Country:US
Practice Address - Phone:801-786-7600
Practice Address - Fax:801-786-7610
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT286410-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT286410-1701OtherDOPL PHARMACIST
UT286410-8911OtherDOPL PHARMACIST CONTROLLED SUBSTANCE