Healthcare Provider Details

I. General information

NPI: 1538284716
Provider Name (Legal Business Name): 12TH ST PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 12TH ST
OGDEN UT
84404-6200
US

IV. Provider business mailing address

698 12TH ST
OGDEN UT
84404-6200
US

V. Phone/Fax

Practice location:
  • Phone: 801-621-2154
  • Fax: 801-627-9523
Mailing address:
  • Phone: 801-621-2154
  • Fax: 801-627-9523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number362500-1703
License Number StateUT

VIII. Authorized Official

Name: WALLACE EGGLESTON
Title or Position: OWNER AND PHARMACIST
Credential:
Phone: 801-621-2154