Provider Demographics
NPI:1396862801
Name:COWLEY, KERMIT KIM (RPH)
Entity Type:Individual
Prefix:
First Name:KERMIT
Middle Name:KIM
Last Name:COWLEY
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 1:1930 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405-9235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2555 N. WOLF CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310
Practice Address - Country:US
Practice Address - Phone:801-745-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346546-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT136546-1701OtherUTAH PHARMACY LICENSE