# 12TH ST PHARMACY INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** 12TH STREET PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1538284716
- **Authorized official:** WALLACE EGGLESTON (OWNER AND PHARMACIST)
- **Authorized official phone:** (801) 621-2154

## Contact information

- **Practice address:** 698 12TH ST, OGDEN, UT 84404-6200
- **Practice address phone:** (801) 621-2154
- **Practice address fax:** (801) 627-9523
- **Mailing address:** 698 12TH ST, OGDEN, UT 84404-6200
- **Mailing address phone:** (801) 621-2154
- **Mailing address fax:** (801) 627-9523

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0002X | Clinic Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 362500-1703 | UT | Yes |

## Other

- **Enumeration date:** 03/20/2007
- **Last updated:** 09/23/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2100182 | PK | — |