Provider Demographics
NPI:1316314099
Name:OLDHAM, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:OLDHAM
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 1:1202 WEST 12600 SOUTH
Mailing Address - Street 2:WAL-MART PHARMACY
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065
Mailing Address - Country:US
Mailing Address - Phone:801-999-2795
Mailing Address - Fax:801-999-2796
Practice Address - Street 1:1202 WEST 12600 SOUTH
Practice Address - Street 2:WAL-MART PHARMACY
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-999-2795
Practice Address - Fax:801-999-2796
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT294623-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist