Provider Demographics
NPI:1932700747
Name:CROCKETT, NICOLE (RPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3866 W SALINAS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7640
Mailing Address - Country:US
Mailing Address - Phone:801-450-8238
Mailing Address - Fax:
Practice Address - Street 1:3590 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8916
Practice Address - Country:US
Practice Address - Phone:801-601-3119
Practice Address - Fax:801-601-3124
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT341246-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist