Provider Demographics
NPI:1881236123
Name:WELCH, MARK NATHAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:NATHAN
Last Name:WELCH
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 1:1174 W 600 N
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-2676
Mailing Address - Country:US
Mailing Address - Phone:801-363-1047
Mailing Address - Fax:801-355-8831
Practice Address - Street 1:1174 W 600 N
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-2676
Practice Address - Country:US
Practice Address - Phone:801-363-1047
Practice Address - Fax:801-355-8831
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368889-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist