Healthcare Provider Details

I. General information

NPI: 1013369602
Provider Name (Legal Business Name): BRIAN TULLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 S STATE ST
OREM UT
84058-6308
US

IV. Provider business mailing address

11976 S WOODRIDGE RD
SANDY UT
84094-5723
US

V. Phone/Fax

Practice location:
  • Phone: 801-426-6650
  • Fax:
Mailing address:
  • Phone: 801-856-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5668530-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: