Healthcare Provider Details

I. General information

NPI: 1821156555
Provider Name (Legal Business Name): CARL JAY SORENSON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3957 S 1599 W
SALT LAKE CITY UT
84123
US

IV. Provider business mailing address

3957 S 1599 W
SALT LAKE CITY UT
84123
US

V. Phone/Fax

Practice location:
  • Phone: 801-975-1855
  • Fax:
Mailing address:
  • Phone: 801-975-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1464991701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: