Healthcare Provider Details

I. General information

NPI: 1316456874
Provider Name (Legal Business Name): JEFFREY RALPH DOERMANN PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 E 800 S
OREM UT
84097-6528
US

IV. Provider business mailing address

648 E 800 S
OREM UT
84097-9319
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-5002
  • Fax: 801-851-5010
Mailing address:
  • Phone: 801-851-5002
  • Fax: 801-851-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number148145-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: