Provider Demographics
NPI:1841382611
Name:CARLSTROM, WALDEMAR NATHANIEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:WALDEMAR
Middle Name:NATHANIEL
Last Name:CARLSTROM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 W 40 S
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1907
Mailing Address - Country:US
Mailing Address - Phone:801-234-8510
Mailing Address - Fax:
Practice Address - Street 1:145 W UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-7316
Practice Address - Country:US
Practice Address - Phone:801-234-8510
Practice Address - Fax:801-234-8522
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT127005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist