Provider Demographics
NPI:1407182892
Name:FOWLER, JACOB CHASE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CHASE
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 E PONY EXPRESS PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005
Mailing Address - Country:US
Mailing Address - Phone:801-753-5100
Mailing Address - Fax:801-753-5101
Practice Address - Street 1:3435 E PONY EXPRESS PKWY STE 150
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005
Practice Address - Country:US
Practice Address - Phone:801-753-5100
Practice Address - Fax:801-753-5101
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6870402-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist