Provider Demographics
NPI:1548628936
Name:ERICKSON, DUSTIN JAMES (PHARMD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JAMES
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 S FOOTHILL DR APT 434
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1958
Mailing Address - Country:US
Mailing Address - Phone:801-231-7358
Mailing Address - Fax:
Practice Address - Street 1:1174 S FOOTHILL DR APT 434
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1958
Practice Address - Country:US
Practice Address - Phone:801-231-7358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5555820-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist