Provider Demographics
NPI:1093846859
Name:SHIELDS, JERRY A (RPH,MBA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:A
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:RPH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1584 W 900 N
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5801
Mailing Address - Country:US
Mailing Address - Phone:801-580-4509
Mailing Address - Fax:
Practice Address - Street 1:1584 W 900 N
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5801
Practice Address - Country:US
Practice Address - Phone:801-580-4509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT151226-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist