Provider Demographics
NPI:1295364859
Name:KETTERING, CHRISTIAN JAY
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:JAY
Last Name:KETTERING
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 1:667 E 9000 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2424
Mailing Address - Country:US
Mailing Address - Phone:801-255-9699
Mailing Address - Fax:801-519-3477
Practice Address - Street 1:667 E 9000 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2424
Practice Address - Country:US
Practice Address - Phone:801-255-9699
Practice Address - Fax:801-519-3477
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9366671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9366671OtherREGISTERED PHARMACIST