Fusion Specialty Pharmacy Inc
Organization Active NPI Community/Retail Pharmacy · Santa Clara, UT
NPI 1508104712 · NPPES record last updated Feb 5, 2025
Key facts
- NPI
- 1508104712
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 1260 (AK)
- Legal business name
- FUSION SPECIALTY PHARMACY INC
- Practice address
- 1100 Canyon View Dr Ste C
Santa Clara, UT 84765-5672 - Phone
- (435) 703-9680
- Fax
- (855) 853-3465
- NPI assigned
- Jan 23, 2013
- Organization subpart
- No
Authorized official
- Name
- Koby Taylor, PHARMD
- Title
- President
- Phone
- (435) 703-9680
Practitioners 2
-
Koby Taylor, PHARM.D., R.PH.
-
Travis Snow, PHARMD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 46D2141733 | Fusion Specialty Pharmacy | Certificate of waiver | Dec 19, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in UT
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210107001205 | UT | Part B Supplier - Pharmacy | 7315350501 | Practice locations: Santa Clara, UT |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 2013016261 | MO | |
| Community/Retail Pharmacy | 3336C0003X | PH02951 | NV | |
| Community/Retail Pharmacy | 3336C0003X | 21457MS | ID | |
| Community/Retail Pharmacy | 3336C0003X | 1260 | AK | Yes |
| Community/Retail Pharmacy | 3336C0003X | 22-13015 | KS | |
| Community/Retail Pharmacy | 3336C0003X | OSP.0006181 | CO | |
| Community/Retail Pharmacy | 3336C0003X | PHA-MOP-LIC-21763 | MT | |
| Community/Retail Pharmacy | 3336C0003X | PMP-966 | HI | |
| Community/Retail Pharmacy | 3336C0003X | RP-0002986-CS | OR | |
| Community/Retail Pharmacy | 3336C0003X | 033401 | NY | |
| Community/Retail Pharmacy | 3336C0003X | PH000039111 | NM | |
| Community/Retail Pharmacy | 3336C0003X | NRP.022647900-03 | OH | |
| Community/Retail Pharmacy | 3336C0003X | 28RO00142300 | NJ | |
| Community/Retail Pharmacy | 3336C0003X | PH30592 | FL | |
| Community/Retail Pharmacy | 3336C0003X | PHNR001096 | GA |
Addresses
Primary practice location
1100 Canyon View Dr Ste C
Santa Clara, UT 84765-5672
Mailing address
1100 Canyon View Dr
Ste C
Santa Clara, UT 84765-5671
Phone (435) 703-9680
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2138783 | Other | PK |
Other names
- Fusion Specialty Pharmacy
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All providers in Santa Clara, UT · Community/Retail Pharmacy in Utah
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 5, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.