Basic Information
| Provider Information | |||||||||
| NPI: | 1295957520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARNER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | TERRY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4314 SUNRISE DR | ||||||||
| Address2: | |||||||||
| City: | EDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533704060 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013872800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH00014676 | WA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | H00014676 | 01 | WA | PHARMACIST LICENSE | OTHER |