Healthcare Provider Details

I. General information

NPI: 1699748863
Provider Name (Legal Business Name): BRUCE E LEAVITT PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 10TH AVE SUITE 124
SALT LAKE CITY UT
84103-2853
US

IV. Provider business mailing address

5502 FJORD CIR
TAYLORSVILLE UT
84118-2357
US

V. Phone/Fax

Practice location:
  • Phone: 801-408-3090
  • Fax:
Mailing address:
  • Phone: 801-966-7895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number151778-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: