Provider Demographics
NPI:1033493150
Name:GARRETT, WYATT
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:
Last Name:GARRETT
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 1:1235 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-3539
Mailing Address - Country:US
Mailing Address - Phone:435-635-1071
Mailing Address - Fax:
Practice Address - Street 1:1235 W STATE ST
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-3539
Practice Address - Country:US
Practice Address - Phone:435-635-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7078650-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist