Healthcare Provider Details

I. General information

NPI: 1568063303
Provider Name (Legal Business Name): SETH WILLIAM POULSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E PARLEYS WAY
SALT LAKE CITY UT
84109-1619
US

IV. Provider business mailing address

103 WILLOW ST
GRANTSVILLE UT
84029-9479
US

V. Phone/Fax

Practice location:
  • Phone: 385-313-3949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7792466-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: