Healthcare Provider Details

I. General information

NPI: 1114089794
Provider Name (Legal Business Name): SOUTHEAST PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 S 2000 E
SALT LAKE CITY UT
84109-1736
US

IV. Provider business mailing address

2670 S 2000 E
SALT LAKE CITY UT
84109-1736
US

V. Phone/Fax

Practice location:
  • Phone: 801-466-2181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1277321703
License Number StateUT

VIII. Authorized Official

Name: ROBERT R HUNTER
Title or Position: PHARMACIST
Credential:
Phone: 801-466-2181