Provider Demographics
NPI:1386167401
Name:SMITH, JEFFERY DAN (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:DAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 560
Mailing Address - Street 2:146 WEST 200 SOUTH
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036
Mailing Address - Country:US
Mailing Address - Phone:435-783-4316
Mailing Address - Fax:435-783-4370
Practice Address - Street 1:146 WEST 200 SOUTH
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036
Practice Address - Country:US
Practice Address - Phone:435-783-4316
Practice Address - Fax:435-783-4370
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144346-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist