Provider Demographics
NPI:1275747768
Name:WILLMORE, MYRLE (RPH)
Entity Type:Individual
Prefix:MS
First Name:MYRLE
Middle Name:
Last Name:WILLMORE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SHADOW MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6757
Mailing Address - Country:US
Mailing Address - Phone:435-787-8474
Mailing Address - Fax:
Practice Address - Street 1:500 E 1400 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2465
Practice Address - Country:US
Practice Address - Phone:435-716-5158
Practice Address - Fax:435-753-7636
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142251-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist