=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952013757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHERYL PETERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2022
-----------------------------------------------------
Last Update Date | 12/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 E 13800 S
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-9557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-617-0123
-----------------------------------------------------
Fax | 801-617-0130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 E 13800 S
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-9557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-617-0123
-----------------------------------------------------
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 | 151929
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------