Provider Demographics
NPI:1134645526
Name:PCO-KTA, LLC
Entity type:Organization
Organization Name:PCO-KTA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:801-827-0688
Mailing Address - Street 1:3673 WEST 2600 NORTH
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404
Mailing Address - Country:US
Mailing Address - Phone:801-827-0688
Mailing Address - Fax:
Practice Address - Street 1:3673 WEST 2600 NORTH
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-827-0688
Practice Address - Fax:801-827-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-17
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy