Provider Demographics
NPI:1790378305
Name:STEVENSON, MICHAEL BLAKE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BLAKE
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3544 W CHATEL DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6855
Mailing Address - Country:US
Mailing Address - Phone:385-209-8938
Mailing Address - Fax:
Practice Address - Street 1:3148 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3634
Practice Address - Country:US
Practice Address - Phone:801-963-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6706922-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist