Provider Demographics
NPI:1821286691
Name:UNIVERSITY OF UTAH SOUTH JORDAN MAIL ORDER PHARMACY
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH SOUTH JORDAN MAIL ORDER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-587-6325
Mailing Address - Street 1:127 S 500 E
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1959
Mailing Address - Country:US
Mailing Address - Phone:801-587-6322
Mailing Address - Fax:
Practice Address - Street 1:1091 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8820
Practice Address - Country:US
Practice Address - Phone:801-213-9850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5546220-17033336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========002Medicaid