Healthcare Provider Details

I. General information

NPI: 1487932075
Provider Name (Legal Business Name): STACY RAE HARBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 S 300 W
SALT LAKE CITY UT
84101-3053
US

IV. Provider business mailing address

6431 S 1865 E
SALT LAKE CITY UT
84121-2119
US

V. Phone/Fax

Practice location:
  • Phone: 801-401-9563
  • Fax:
Mailing address:
  • Phone: 801-440-4063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7115078-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: