Provider Demographics
NPI:1962787275
Name:COLEMAN, EMMET (RPH)
Entity type:Individual
Prefix:
First Name:EMMET
Middle Name:
Last Name:COLEMAN
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:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1077
Mailing Address - Country:US
Mailing Address - Phone:801-572-9275
Mailing Address - Fax:
Practice Address - Street 1:12623 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6606
Practice Address - Country:US
Practice Address - Phone:801-254-4916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT58504281701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist