Provider Demographics
NPI:1922642198
Name:KOELLIKER, MARK C
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:KOELLIKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10309 S GRANITE MESA CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-7206
Mailing Address - Country:US
Mailing Address - Phone:801-942-4478
Mailing Address - Fax:
Practice Address - Street 1:980 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1714
Practice Address - Country:US
Practice Address - Phone:801-256-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144234-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist