Healthcare Provider Details

I. General information

NPI: 1760602148
Provider Name (Legal Business Name): JEAROLD W YACK RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 AUTO MALL DR
SANDY UT
84070-4171
US

IV. Provider business mailing address

11100 AUTO MALL DR
SANDY UT
84070-4171
US

V. Phone/Fax

Practice location:
  • Phone: 801-790-0002
  • Fax: 801-790-0009
Mailing address:
  • Phone: 801-790-0002
  • Fax: 801-790-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1437271701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: