Provider Demographics
NPI:1417385014
Name:JENSEN, THOMAS RALPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RALPH
Last Name:JENSEN
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 1:421 E 2825 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4240
Mailing Address - Country:US
Mailing Address - Phone:801-822-8086
Mailing Address - Fax:
Practice Address - Street 1:3179 N CANYON RD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3916
Practice Address - Country:US
Practice Address - Phone:801-377-2002
Practice Address - Fax:801-377-2007
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013823183500000X
UT7725489-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist