Healthcare Provider Details

I. General information

NPI: 1073125373
Provider Name (Legal Business Name): BRENDA LEE WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 N REDWOOD RD
SALT LAKE CITY UT
84116-1909
US

IV. Provider business mailing address

PO BOX 16495
SALT LAKE CITY UT
84116
US

V. Phone/Fax

Practice location:
  • Phone: 801-532-3795
  • Fax: 801-532-4909
Mailing address:
  • Phone: 801-532-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number9250968-1717
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: