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NPI Code Detail

MEDICARE: DEREK JAMES TULLY

MEDICARE: DEREK JAMES TULLY
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
1183500000XPharmacist7685428-1701UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17685428-8911OTHERUTUTAH DEPARTMENT OF PROFESSIONAL LICENSING
27685428-1701OTHERUTUTAH DEPARTMENT OF PROFESSIONAL LICENSING

General Provider Information

NPI Number : 1972114007
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEREK JAMES TULLY
Provider Business Mailing Address
First Line : 8649 N PINE VALLEY ALY
Second Line :
City : EAGLE MOUNTAIN
State : UT
Zip : 84005-5261
Country : US
Telephone Number : 256-654-0882
Fax Number :
Provider Business Practice Location Address
First Line : 2332 E 2100 S
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84109-1319
Country : US
Telephone Number : 801-466-9949
Fax Number : 801-467-6742
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/12/2020
Last Update Date : 08/12/2020

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