Healthcare Provider Details

I. General information

NPI: 1295678464
Provider Name (Legal Business Name): JONATHAN SANDOVAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3863 W 9000 S
WEST JORDAN UT
84088-8856
US

IV. Provider business mailing address

3863 W 9000 S
WEST JORDAN UT
84088-8856
US

V. Phone/Fax

Practice location:
  • Phone: 801-280-1245
  • Fax: 801-280-4391
Mailing address:
  • Phone: 801-280-1245
  • Fax: 801-280-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9175711-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: