Provider Demographics
NPI:1710254875
Name:DIESTERHAFT, KELLY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:DIESTERHAFT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 WEST 4700 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118
Mailing Address - Country:US
Mailing Address - Phone:801-213-9200
Mailing Address - Fax:
Practice Address - Street 1:3730 W 4700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84129-3457
Practice Address - Country:US
Practice Address - Phone:801-213-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7317273-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist