Provider Demographics
NPI:1649509233
Name:STEWART, ALISA JORGENSEN
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:JORGENSEN
Last Name:STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:GAIL
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:900 VILLAGE BEND LN
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5685
Mailing Address - Country:US
Mailing Address - Phone:801-214-5567
Mailing Address - Fax:
Practice Address - Street 1:4190 HIGHLAND DR STE 250
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84124-2781
Practice Address - Country:US
Practice Address - Phone:877-879-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4822083-8911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist