Active NPI
Mark C Koelliker
- Pharmacist
- Midvale, UT
National Provider Identifier
1922642198
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 144234-1701
- Practice address
- 980 E Fort Union Blvd
Midvale, UT 84047-1714 - Phone
- (801) 256-0532
- NPI assigned
- Oct 31, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 144234-1701 | UT | Primary |
Addresses
Primary practice location
980 E Fort Union Blvd
Midvale, UT 84047-1714
Mailing address
10309 S Granite Mesa Cir
Sandy, UT 84092-7206
Phone (801) 942-4478
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 144234-1701 | UT | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1572480000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1572480000000",
"number": "1922642198",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10309 S GRANITE MESA CIR",
"city": "SANDY",
"state": "UT",
"postal_code": "840927206",
"telephone_number": "801-942-4478"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "980 E FORT UNION BLVD",
"city": "MIDVALE",
"state": "UT",
"postal_code": "840471714",
"telephone_number": "801-256-0532"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KOELLIKER",
"first_name": "MARK",
"middle_name": "C",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2019-10-31",
"last_updated": "2019-10-31",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "UT",
"license": "144234-1701",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Midvale, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.