Healthcare Provider Details

I. General information

NPI: 1588927792
Provider Name (Legal Business Name): OLIVE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 S REDWOOD RD
WEST VALLEY CITY UT
84119-1322
US

IV. Provider business mailing address

2290 S REDWOOD RD
WEST VALLEY CITY UT
84119-1322
US

V. Phone/Fax

Practice location:
  • Phone: 801-972-5155
  • Fax: 801-972-5152
Mailing address:
  • Phone: 801-972-5155
  • Fax: 801-972-5152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. KAMRAN M KHAN
Title or Position: PHARMACY MANAGER
Credential:
Phone: 801-972-5155