Healthcare Provider Details

I. General information

NPI: 1124579313
Provider Name (Legal Business Name): ANTHONY MATTHEW MAZZA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2016
Last Update Date: 10/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2353 N MAIN ST
SUNSET UT
84015-2454
US

IV. Provider business mailing address

1566 34TH ST
OGDEN UT
84403-1366
US

V. Phone/Fax

Practice location:
  • Phone: 801-825-2262
  • Fax: 801-773-3989
Mailing address:
  • Phone: 801-627-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5039647-1701
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3916
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: