Provider Demographics
NPI:1811548001
Name:LAM, TRISTAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:LAM
Suffix:
Gender:M
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:PO BOX 711601
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1601
Mailing Address - Country:US
Mailing Address - Phone:801-674-5457
Mailing Address - Fax:
Practice Address - Street 1:1174 W 600 N
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-2676
Practice Address - Country:US
Practice Address - Phone:801-363-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6182995-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist