Provider Demographics
NPI:1003457011
Name:CARTER, JOHNATHAN OTTO (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:OTTO
Last Name:CARTER
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2810
Mailing Address - Country:US
Mailing Address - Phone:801-377-9250
Mailing Address - Fax:
Practice Address - Street 1:350 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2810
Practice Address - Country:US
Practice Address - Phone:801-377-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8071132-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist