Healthcare Provider Details

I. General information

NPI: 1205061538
Provider Name (Legal Business Name): PCM VENTURE I PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9836 S JORDAN GTWY
SANDY UT
84070-9509
US

IV. Provider business mailing address

9836 S JORDAN GTWY
SANDY UT
84070-9509
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-6601
  • Fax: 801-262-6636
Mailing address:
  • Phone: 801-262-6601
  • Fax: 801-262-6636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number StateUT

VIII. Authorized Official

Name: MR. PETER AX
Title or Position: OWNER
Credential:
Phone: 480-707-4534