Provider Demographics
NPI:1316990518
Name:CHRISTENSEN, CORY ALAN (RPH)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:ALAN
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 3090
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-9612
Mailing Address - Country:US
Mailing Address - Phone:435-722-4954
Mailing Address - Fax:435-722-4191
Practice Address - Street 1:245 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3710
Practice Address - Country:US
Practice Address - Phone:435-722-2454
Practice Address - Fax:435-722-4191
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT147117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870672738008Medicaid
UT4528330001Medicare ID - Type UnspecifiedPHARMACY