Provider Demographics
NPI:1487165122
Name:STANFORD, BUCK EDWARD (RPH, MBA)
Entity type:Individual
Prefix:
First Name:BUCK
Middle Name:EDWARD
Last Name:STANFORD
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4393 S RIVERBOAT RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2503
Mailing Address - Country:US
Mailing Address - Phone:801-284-1005
Mailing Address - Fax:
Practice Address - Street 1:4393 S RIVERBOAT RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-2503
Practice Address - Country:US
Practice Address - Phone:801-284-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-21
Last Update Date:2017-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019282A183500000X
UT885982917011835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care