MEDICARE: COLIN KELLY CREBS NUCLEAR PHARMACIST

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	1835N0905X	Nuclear Pharmacist	145579-1701	UT

General Provider Information

NPI Number	:	1629236591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLIN KELLY CREBS NUCLEAR PHARMACIST

Provider Business Mailing Address
First Line	:	391 CHIPETA WAY SUITE A
Second Line	:	INTERMOUNTAIN RADIOPHARMACY
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2703
Country	:	US
Telephone Number	:	801-581-8189
Fax Number	:	801-585-7273

Provider Business Practice Location Address
First Line	:	391 CHIPETA WAY
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1263
Country	:	US
Telephone Number	:	801-581-8189
Fax Number	:	801-585-7273

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

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	05/28/2008

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