MEDICARE: DAVID LEE DEHERRERA RPH

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	274426-1701	UT

General Provider Information

NPI Number	:	1679840334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID LEE DEHERRERA RPH

Provider Business Mailing Address
First Line	:	5630 W 4100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84128-4338
Country	:	US
Telephone Number	:	801-840-5155
Fax Number	:

Provider Business Practice Location Address
First Line	:	5630 W 4100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84128-4338
Country	:	US
Telephone Number	:	801-840-5155
Fax Number	:

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

Provider Enumeration Date	:	11/23/2011
Last Update Date	:	11/23/2011

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