1699705558 NPI number — DR. BONNIE KATHLEEN PORTLEY PHARM.D.

Table of content: DR. BONNIE KATHLEEN PORTLEY PHARM.D. (NPI 1699705558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699705558 NPI number — DR. BONNIE KATHLEEN PORTLEY PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTLEY
Provider First Name:
BONNIE
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699705558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PHARMACY SERVICES #119
Provider Second Line Business Mailing Address:
500 FOOTHILL BLVD.
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84148-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-582-1565
Provider Business Mailing Address Fax Number:
801-584-2587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PHARMACY SERVICES #119
Provider Second Line Business Practice Location Address:
500 FOOTHILL BLVD.
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84148-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-582-1565
Provider Business Practice Location Address Fax Number:
801-584-2587
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1835P1200X , with the licence number:  2737311701 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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