Provider Demographics
NPI:1487743076
Name:UNIVERSITY OF UTAH
Entity type:Organization
Organization Name:UNIVERSITY OF UTAH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-6325
Mailing Address - Street 1:PO BOX 511124
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84151-1124
Mailing Address - Country:US
Mailing Address - Phone:801-587-6325
Mailing Address - Fax:801-236-8043
Practice Address - Street 1:200 S CENTRAL CAMPUS DR
Practice Address - Street 2:ROOM 156
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-9149
Practice Address - Country:US
Practice Address - Phone:801-587-3363
Practice Address - Fax:801-236-8043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
UT578477917033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4610297OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4610297OtherNCPDP PROVIDER IDENTIFICATION NUMBER