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General NPI Number Information
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NPI Number | 1396827077
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Entity Type | Organization
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Legal Business Name | DIVERSIFIED PROFESSIONAL COMPANY
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 02/19/2008
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Provider Practice Location Address
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Address Line | 4650 HARRISON BLVD
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City | OGDEN
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State | UT
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Zip | 84403-4303
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Country | US
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Telephone | 801-479-4030
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Fax | 801-475-7051
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Provider Business Mailing Address
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Address Line | PO BOX 150010
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City | OGDEN
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State | UT
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Zip | 84415-0010
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Country | US
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Telephone | 801-479-4030
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Fax | 801-475-7051
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. GARY LYNN BAILEY
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Credential | RPH
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Telephone | 801-479-4030
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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 | 132801-1703
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License Number State | UT
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