Healthcare Provider Details

I. General information

NPI: 1508269887
Provider Name (Legal Business Name): STEVEN GRANT HULTGREN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE H
POWELL WY
82435-2260
US

IV. Provider business mailing address

777 AVENUE H
POWELL WY
82435-2260
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-1279
  • Fax: 307-754-7732
Mailing address:
  • Phone: 307-754-1279
  • Fax: 307-754-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number3346
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: