Provider Demographics
NPI:1578864369
Name:MIJARES, CARLOS AUGUSTO (PHARMACY INTERN)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:AUGUSTO
Last Name:MIJARES
Suffix:
Gender:M
Credentials:PHARMACY INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 S 1400 E
Mailing Address - Street 2:C/O MARK DALLIN
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-9704
Mailing Address - Country:US
Mailing Address - Phone:801-787-6828
Mailing Address - Fax:
Practice Address - Street 1:10920 RIVER FRONT PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3538
Practice Address - Country:US
Practice Address - Phone:801-302-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7210693-1702390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program