Organization
12TH ST PHARMACY INC
Active
Other names
12TH STREET PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
WALLACE EGGLESTON (OWNER AND PHARMACIST)
(801) 621-2154
Entity
Organization
Contact information
Practice address
698 12TH ST, OGDEN, UT 84404-6200
(801) 621-2154
(801) 627-9523
Mailing address
698 12TH ST, OGDEN, UT 84404-6200
(801) 621-2154
(801) 627-9523
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0002X
Clinic Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
362500-1703
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2100182
PK
—
Enumeration date
03/20/2007
Last updated
09/23/2016
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