Healthcare Provider Details

I. General information

NPI: 1164912374
Provider Name (Legal Business Name): JARON ANDREW STOUT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 E 100 N
LOGAN UT
84321-4873
US

IV. Provider business mailing address

PO BOX 239
RUPERT ID
83350-0239
US

V. Phone/Fax

Practice location:
  • Phone: 888-853-8973
  • Fax: 888-959-9385
Mailing address:
  • Phone: 888-221-0423
  • Fax: 888-271-9816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number6947461-1701
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6947461-1701
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerSTATE OF UTAH PHARMACIST LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: