Healthcare Provider Details

I. General information

NPI: 1336216860
Provider Name (Legal Business Name): NICHOLAS COSENTINO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7321 11TH ST BUILDING 570
HILL AFB UT
84056-5012
US

IV. Provider business mailing address

5795 CASSIE DR
SOUTH OGDEN UT
84405-4843
US

V. Phone/Fax

Practice location:
  • Phone: 801-777-0418
  • Fax:
Mailing address:
  • Phone: 801-777-0419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6230744-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: