Healthcare Provider Details

I. General information

NPI: 1154640555
Provider Name (Legal Business Name): WADE R POULSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 N SCOTCH PINE DR
DUCHESNE UT
84021-0464
US

IV. Provider business mailing address

PO BOX 464
DUCHESNE UT
84021-0464
US

V. Phone/Fax

Practice location:
  • Phone: 435-738-0155
  • Fax: 435-738-0153
Mailing address:
  • Phone: 801-389-0267
  • Fax: 435-738-0153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WADE POULSON
Title or Position: OWNER
Credential:
Phone: 801-389-0267