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General NPI Number Information
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NPI Number | 1154640555
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Entity Type | Organization
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Legal Business Name | WADE R POULSON
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Dates
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Enumeration Date | 05/25/2010
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Last Update Date | 11/12/2010
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Provider Practice Location Address
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Address Line | 1322 N SCOTCH PINE DR
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City | DUCHESNE
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State | UT
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Zip | 84021-0464
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Country | US
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Telephone | 435-738-0155
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Fax | 435-738-0153
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Provider Business Mailing Address
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Address Line | PO BOX 464
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City | DUCHESNE
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State | UT
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Zip | 84021-0464
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Country | US
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Telephone | 801-389-0267
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Fax | 435-738-0153
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Authorized Official
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Title or Position | OWNER
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Name | WADE POULSON
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Credential |
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Telephone | 801-389-0267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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