MEDICARE: TAD HENRY JOLLEY RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	1517711701	UT

General Provider Information

NPI Number	:	1669582045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAD HENRY JOLLEY RPH

Provider Business Mailing Address
First Line	:	8806 REDWOOD RD
Second Line	:	SUITE 102
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-9337
Country	:	US
Telephone Number	:	801-747-7500
Fax Number	:	801-747-7504

Provider Business Practice Location Address
First Line	:	8806 REDWOOD RD
Second Line	:	SUITE 102
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-9337
Country	:	US
Telephone Number	:	801-747-7500
Fax Number	:	801-747-7504

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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