=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679208680
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALEB ROBERTS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2022
-----------------------------------------------------
Last Update Date | 07/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5056 W 13400 S
-----------------------------------------------------
City | HERRIMAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-981-1680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2636 W 12875 S
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84065-6751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 8355610-1701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------