Provider Demographics
NPI:1073125373
Name:WALLER, BRENDA LEE
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16495
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116
Mailing Address - Country:US
Mailing Address - Phone:801-532-3795
Mailing Address - Fax:
Practice Address - Street 1:729 N REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-1909
Practice Address - Country:US
Practice Address - Phone:801-532-3795
Practice Address - Fax:801-532-4909
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9250968-1717183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician