Provider Demographics
NPI:1558612176
Name:IVIE, CLINT C (RPH)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:C
Last Name:IVIE
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 1:608 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9762
Mailing Address - Country:US
Mailing Address - Phone:801-756-5997
Mailing Address - Fax:
Practice Address - Street 1:608 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-9762
Practice Address - Country:US
Practice Address - Phone:801-756-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7362710-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist