Provider Demographics
NPI:1073247268
Name:JOLLEY, LEO DEAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:DEAN
Last Name:JOLLEY
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 1:1702 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3424
Mailing Address - Country:US
Mailing Address - Phone:801-484-4393
Mailing Address - Fax:801-484-8677
Practice Address - Street 1:1702 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3424
Practice Address - Country:US
Practice Address - Phone:801-484-4393
Practice Address - Fax:801-484-8677
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145642-17011835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT145642-1701OtherUTAH PHARMACIST LICENSE