Provider Demographics
NPI:1184367757
Name:WARREN, JONATHAN RANDALL (PHARMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RANDALL
Last Name:WARREN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 S 2885 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-7031
Mailing Address - Country:US
Mailing Address - Phone:385-985-7897
Mailing Address - Fax:
Practice Address - Street 1:1208 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5743
Practice Address - Country:US
Practice Address - Phone:801-621-1367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104781781701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist