Provider Demographics
NPI:1770525552
Name:PROFESSIONAL PHARMACY SERVICES
Entity type:Organization
Organization Name:PROFESSIONAL PHARMACY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:801-743-2800
Mailing Address - Street 1:3793 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4828
Mailing Address - Country:US
Mailing Address - Phone:801-263-5466
Mailing Address - Fax:
Practice Address - Street 1:3793 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4828
Practice Address - Country:US
Practice Address - Phone:801-263-5466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT663791617043336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4610398OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4610398OtherNCPDP PROVIDER IDENTIFICATION NUMBER