Healthcare Provider Details

I. General information

NPI: 1356257836
Provider Name (Legal Business Name): MARYAM EBRAHIMI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6306 S AIRPORT RD
WEST JORDAN UT
84084-5601
US

IV. Provider business mailing address

3970 S 700 W APT 115
SLC UT
84123-7835
US

V. Phone/Fax

Practice location:
  • Phone: 801-432-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number109001601701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: