Healthcare Provider Details

I. General information

NPI: 1891283735
Provider Name (Legal Business Name): ALTA RX LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9883 SOUTH 500 WEST
SANDY UT
84070
US

IV. Provider business mailing address

9883 SOUTH 500 WEST
SANDY UT
84070
US

V. Phone/Fax

Practice location:
  • Phone: 801-716-7200
  • Fax: 801-716-7202
Mailing address:
  • Phone: 801-716-7200
  • Fax: 801-716-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number10738486-1703
License Number StateUT

VIII. Authorized Official

Name: NICOLE ELISABETH COX
Title or Position: PIC
Credential: RPH
Phone: 801-716-7200