Healthcare Provider Details

I. General information

NPI: 1710254875
Provider Name (Legal Business Name): KELLY DIESTERHAFT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3730 W 4700 S
SALT LAKE CITY UT
84129-3457
US

IV. Provider business mailing address

3730 WEST 4700 SOUTH
WEST VALLEY CITY UT
84118
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-9200
  • Fax:
Mailing address:
  • Phone: 801-213-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7317273-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: