=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104915792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF UTAH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 03/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 S MAIN ST STE 100
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84014-1817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-693-7950
-----------------------------------------------------
Fax | 801-693-7955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 841208
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90084-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-587-6334
-----------------------------------------------------
Fax | 801-587-2996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY BUSINESS OPERATION MANAGER
-----------------------------------------------------
Name | KELLEE K HOWELL
-----------------------------------------------------
Credential | CPHT
-----------------------------------------------------
Telephone | 801-587-6334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 62502141703
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------