Healthcare Provider Details

I. General information

NPI: 1659612737
Provider Name (Legal Business Name): LIFECARE SPECIALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1646 SUNRISE PLACE STE B
WEST JORDAN UT
84084
US

IV. Provider business mailing address

1646 SUNRISE PLACE STE B
WEST JORDAN UT
84084
US

V. Phone/Fax

Practice location:
  • Phone: 801-676-0078
  • Fax: 801-676-0079
Mailing address:
  • Phone: 801-676-0078
  • Fax: 801-676-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number84735471704
License Number StateUT
# 5
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number8473547-1704
License Number StateUT

VIII. Authorized Official

Name: MR. TYLER L NIXON
Title or Position: OWNER
Credential: RPH
Phone: 801-676-0078