Healthcare Provider Details

I. General information

NPI: 1831269331
Provider Name (Legal Business Name): LYNN I WAWRINOFSKY PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

597 FREE LAND AVE
MIDVALE UT
84047-4644
US

IV. Provider business mailing address

597 FREE LAND AVE
MIDVALE UT
84047-4644
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-0134
  • Fax:
Mailing address:
  • Phone: 801-566-0134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1409758911
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: