Provider Demographics
NPI:1104427202
Name:THOMPSON, PAUL LORREN
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LORREN
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 W 1900 S
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 W CENTER ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4276
Practice Address - Country:US
Practice Address - Phone:801-374-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT150619-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist