Provider Demographics
NPI:1972114007
Name:TULLY, DEREK JAMES
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:TULLY
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 1:8649 N PINE VALLEY ALY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5261
Mailing Address - Country:US
Mailing Address - Phone:256-654-0882
Mailing Address - Fax:
Practice Address - Street 1:2332 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-1319
Practice Address - Country:US
Practice Address - Phone:801-466-9949
Practice Address - Fax:801-467-6742
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7685428-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7685428-8911OtherUTAH DEPARTMENT OF PROFESSIONAL LICENSING
UT7685428-1701OtherUTAH DEPARTMENT OF PROFESSIONAL LICENSING