Provider Demographics
NPI:1760890016
Name:WASATCH FRONT LTC PHARMACY
Entity Type:Organization
Organization Name:WASATCH FRONT LTC PHARMACY
Other - Org Name:PIONEER PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-890-0346
Mailing Address - Street 1:11585 S STATE ST
Mailing Address - Street 2:STE 103
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7400
Mailing Address - Country:US
Mailing Address - Phone:801-890-0346
Mailing Address - Fax:801-542-0491
Practice Address - Street 1:11585 S STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7403
Practice Address - Country:US
Practice Address - Phone:801-890-0346
Practice Address - Fax:801-542-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9012387-17043336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147019OtherPK