Healthcare Provider Details

I. General information

NPI: 1265963573
Provider Name (Legal Business Name): KIRTLAND J. WRAY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1859 S 580 W
WOODS CROSS UT
84087-1644
US

IV. Provider business mailing address

1859 S 580 W
WOODS CROSS UT
84087-1644
US

V. Phone/Fax

Practice location:
  • Phone: 801-866-4659
  • Fax:
Mailing address:
  • Phone: 801-866-4659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number144529-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: