Provider Demographics
NPI:1306126073
Name:ALBERTSEN, CARMEN MEDINA (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MEDINA
Last Name:ALBERTSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E 100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-6500
Mailing Address - Country:US
Mailing Address - Phone:801-428-0399
Mailing Address - Fax:
Practice Address - Street 1:135 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-6500
Practice Address - Country:US
Practice Address - Phone:801-428-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6571183500000X
UT800057451701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist