MEDICARE: NINA IVANOVA

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	183500000X	Pharmacist	292261	UT

General Provider Information

NPI Number	:	1417559451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA IVANOVA

Provider Business Mailing Address
First Line	:	6545 N LANDMARK DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5990
Country	:	US
Telephone Number	:	435-647-9040
Fax Number	:	435-647-9042

Provider Business Practice Location Address
First Line	:	6545 N LANDMARK DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5990
Country	:	US
Telephone Number	:	435-647-9040
Fax Number	:	435-647-9042

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2020
Last Update Date	:	11/13/2020

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Directions to “ NINA IVANOVA ” Practice Location

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