Healthcare Provider Details

I. General information

NPI: 1548363831
Provider Name (Legal Business Name): SUSAN L SMITH R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S CENTRAL CAMPUS DR RM 156
SALT LAKE CITY UT
84112-9149
US

IV. Provider business mailing address

2660 FILMORE ST
SALT LAKE CITY UT
84106-3604
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-3363
  • Fax: 801-587-3375
Mailing address:
  • Phone: 801-487-9115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number151810-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: