MEDICARE: PCO-KTA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1134645526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PCO-KTA, LLC

Provider Business Mailing Address
First Line	:	3673 WEST 2600 NORTH
Second Line	:
City	:	PLAIN CITY
State	:	UT
Zip	:	84404
Country	:	US
Telephone Number	:	801-827-0688
Fax Number	:

Provider Business Practice Location Address
First Line	:	3673 WEST 2600 NORTH
Second Line	:
City	:	PLAIN CITY
State	:	UT
Zip	:	84404
Country	:	US
Telephone Number	:	801-827-0688
Fax Number	:	801-827-0698

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MARK SCHULTZ
Credential	:	PHARMD
Telephone Number	:	801-827-0688

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	10/24/2017

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