1629236591 NPI number — COLIN KELLY CREBS NUCLEAR PHARMACIST

Table of content: COLIN KELLY CREBS NUCLEAR PHARMACIST (NPI 1629236591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629236591 NPI number — COLIN KELLY CREBS NUCLEAR PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CREBS
Provider First Name:
COLIN
Provider Middle Name:
KELLY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NUCLEAR PHARMACIST
Provider Gender Code:
M

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:
1629236591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
391 CHIPETA WAY SUITE A
Provider Second Line Business Mailing Address:
INTERMOUNTAIN RADIOPHARMACY
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84108-2703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-581-8189
Provider Business Mailing Address Fax Number:
801-585-7273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 CHIPETA WAY
Provider Second Line Business Practice Location Address:
SUITE A
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:
84108-1263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-8189
Provider Business Practice Location Address Fax Number:
801-585-7273
Provider Enumeration Date:
05/28/2008

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: 1835N0905X , with the licence number:  145579-1701 , 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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