Provider Demographics
NPI:1205150414
Name:MORTENSEN, HYRUM KIMBALL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:HYRUM
Middle Name:KIMBALL
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 E 7800 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5803
Mailing Address - Country:US
Mailing Address - Phone:801-943-0177
Mailing Address - Fax:801-944-1253
Practice Address - Street 1:3470 E 7800 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-5803
Practice Address - Country:US
Practice Address - Phone:801-943-0177
Practice Address - Fax:801-944-1253
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4878960-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist