Healthcare Provider Details

I. General information

NPI: 1588724397
Provider Name (Legal Business Name): JOLLEY'S CORNER VARIETY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1676 E 1300 S
SALT LAKE CITY UT
84105-1704
US

IV. Provider business mailing address

1676 E 1300 S
SALT LAKE CITY UT
84105-1704
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1999
  • Fax: 801-582-1270
Mailing address:
  • Phone: 801-582-1999
  • Fax: 801-582-1270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number57508311717
License Number StateUT

VIII. Authorized Official

Name: M BRYCE JOLLEY
Title or Position: PRESIDENT
Credential:
Phone: 801-582-1999