Healthcare Provider Details

I. General information

NPI: 1487117255
Provider Name (Legal Business Name): JEREMY IVIE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N 250 W
SALINA UT
84654-5514
US

IV. Provider business mailing address

PO BOX 129
SALINA UT
84654-0129
US

V. Phone/Fax

Practice location:
  • Phone: 435-529-5988
  • Fax: 435-529-4284
Mailing address:
  • Phone: 435-529-5988
  • Fax: 435-529-4284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7116276-8911
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7116276-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: