Healthcare Provider Details

I. General information

NPI: 1346881851
Provider Name (Legal Business Name): EDEM KOFFI AMEVOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2019
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2039 E 9400 S
SANDY UT
84093-3100
US

IV. Provider business mailing address

3215 S VALLEY ST
SALT LAKE CITY UT
84109-4217
US

V. Phone/Fax

Practice location:
  • Phone: 801-942-2227
  • Fax: 801-943-7436
Mailing address:
  • Phone: 801-486-8477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6432485-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: