1194761585 NPI number — ROOTS PHARMACEUTICALS INC

Table of content: (NPI 1194761585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194761585 NPI number — ROOTS PHARMACEUTICALS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROOTS PHARMACEUTICALS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194761585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 W 100 N
Provider Second Line Business Mailing Address:
STE 201B
Provider Business Mailing Address City Name:
AMERICAN FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-1611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 W 100 N
Provider Second Line Business Practice Location Address:
STE 201B
Provider Business Practice Location Address City Name:
AMERICAN FORK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84003-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-760-2934
Provider Business Practice Location Address Fax Number:
559-756-7600
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROOTSAERT
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
559-760-2934

Provider Taxonomy Codes

  • Taxonomy code: 3336M0002X , with the licence number:  60531781703 , 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)

  • Identifier: 4610451 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4610451 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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