Provider Demographics
NPI:1790306488
Name:GOLTRA, LESLIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GOLTRA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1975 E FALCONHURST CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-3923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8749351-17011835P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0200XPharmacy Service ProvidersPharmacistPediatrics