Provider Demographics
NPI:1386285294
Name:CHRISTENSEN, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11548 S WATERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7937
Mailing Address - Country:US
Mailing Address - Phone:801-440-3522
Mailing Address - Fax:
Practice Address - Street 1:1634 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4562
Practice Address - Country:US
Practice Address - Phone:801-254-0068
Practice Address - Fax:801-253-2561
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT150182-1701333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy