Healthcare Provider Details

I. General information

NPI: 1417385014
Provider Name (Legal Business Name): THOMAS RALPH JENSEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3179 N CANYON RD
PROVO UT
84604-3916
US

IV. Provider business mailing address

421 E 2825 N
PROVO UT
84604-4240
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-2002
  • Fax: 801-377-2007
Mailing address:
  • Phone: 801-822-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0013823
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7725489-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: