Provider Demographics
NPI:1720647720
Name:LASS, ERWIN M
Entity Type:Individual
Prefix:
First Name:ERWIN
Middle Name:M
Last Name:LASS
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 1:11323 S 675 W
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4080
Mailing Address - Country:US
Mailing Address - Phone:801-664-3234
Mailing Address - Fax:
Practice Address - Street 1:4045 E PONY EXPRESS PKWY
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5512
Practice Address - Country:US
Practice Address - Phone:801-789-4997
Practice Address - Fax:801-789-4993
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144072-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist