Healthcare Provider Details

I. General information

NPI: 1487736161
Provider Name (Legal Business Name): DIVERSIFIED PROFESSIONAL COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 E 12TH STREET
OGDEN UT
84404-5144
US

IV. Provider business mailing address

1159 E 12TH STREET
OGDEN UT
84404-5144
US

V. Phone/Fax

Practice location:
  • Phone: 801-334-3190
  • Fax: 801-334-3193
Mailing address:
  • Phone: 801-334-3190
  • Fax: 801-334-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier870218488006
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: MR. GARY LYNN BAILEY
Title or Position: PRESIDENT
Credential: RPH
Phone: 801-334-3190