Healthcare Provider Details

I. General information

NPI: 1245459627
Provider Name (Legal Business Name): MEDIPHARM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 VINE ST
SALT LAKE CITY UT
84121-1700
US

IV. Provider business mailing address

PO BOX 71428
COTTONWOOD UT
84171-0428
US

V. Phone/Fax

Practice location:
  • Phone: 801-733-9902
  • Fax: 801-733-9998
Mailing address:
  • Phone: 801-733-9902
  • Fax: 801-733-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number9680-07
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number375923-1704
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number375923-1704
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number375923-1704
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number375923-1704
License Number StateUT

VIII. Authorized Official

Name: PAUL DUNN
Title or Position: V.P.
Credential:
Phone: 801-839-9079