MEDICARE: SALT LAKE CITY PHARMACY 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	:	1265908719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALT LAKE CITY PHARMACY LLC

Provider Business Mailing Address
First Line	:	6826 S HIGHLAND DR
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3021
Country	:	US
Telephone Number	:	801-783-8025
Fax Number	:	801-733-9998

Provider Business Practice Location Address
First Line	:	6826 S HIGHLAND DR
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3021
Country	:	US
Telephone Number	:	801-783-8025
Fax Number	:	801-733-9998

Authorized Official
Title or Position	:	VP
Name	:	WALKER BATEMAN
Credential	:
Telephone Number	:	801-783-8025

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	10/22/2018

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