MEDICARE: DR. LISA MAUREEN ANGELOS PHARMD, BCSCP, CAPP

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	7054807-1701	UT

General Provider Information

NPI Number	:	1699497222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA MAUREEN ANGELOS PHARMD, BCSCP, CAPP

Provider Business Mailing Address
First Line	:	10221 S YUBA WAY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-5547
Country	:	US
Telephone Number	:	801-647-3537
Fax Number	:

Provider Business Practice Location Address
First Line	:	10221 S YUBA WAY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-5547
Country	:	US
Telephone Number	:	801-647-3537
Fax Number	:

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

Provider Enumeration Date	:	09/12/2022
Last Update Date	:	09/12/2022

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