Provider Demographics
NPI:1699394429
Name:TREADWELL, MARIAH ANN
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ANN
Last Name:TREADWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 E MIDVILLAGE BLVD APT 406
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-1290
Mailing Address - Country:US
Mailing Address - Phone:207-740-7348
Mailing Address - Fax:
Practice Address - Street 1:2330 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3339
Practice Address - Country:US
Practice Address - Phone:801-308-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-12
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPI46029390200000X
UT11701316-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program