Provider Demographics
NPI:1326930082
Name:FOREST, JEDEDIAH
Entity type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:
Last Name:FOREST
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 1:1120 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-3433
Mailing Address - Country:US
Mailing Address - Phone:435-635-3840
Mailing Address - Fax:435-635-1696
Practice Address - Street 1:1120 W STATE ST
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-3433
Practice Address - Country:US
Practice Address - Phone:435-635-3840
Practice Address - Fax:435-635-1696
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7140541-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist