MEDICARE: DR. KELLY DIESTERHAFT PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	7317273-1701	UT

General Provider Information

NPI Number	:	1710254875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY DIESTERHAFT PHARMD

Provider Business Mailing Address
First Line	:	3730 WEST 4700 SOUTH
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84118
Country	:	US
Telephone Number	:	801-213-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3730 W 4700 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-3457
Country	:	US
Telephone Number	:	801-213-9200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2011
Last Update Date	:	11/17/2011

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