Healthcare Provider Details

I. General information

NPI: 1821639170
Provider Name (Legal Business Name): TRACE R HELLSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TRACE R HELLSTROM PHARMD

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2343 N 400 E
NORTH OGDEN UT
84414-7232
US

IV. Provider business mailing address

2343 N 400 E
NORTH OGDEN UT
84414-7232
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-1492
  • Fax: 801-917-1492
Mailing address:
  • Phone: 801-917-1492
  • Fax: 801-917-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7034860-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: