Provider Demographics
NPI:1588673016
Name:JER KEN INC
Entity Type:Organization
Organization Name:JER KEN INC
Other - Org Name:KENT'S THRIFTWAY PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGGARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:435-723-8841
Mailing Address - Street 1:260 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2120
Mailing Address - Country:US
Mailing Address - Phone:435-723-8841
Mailing Address - Fax:435-734-9567
Practice Address - Street 1:260 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2120
Practice Address - Country:US
Practice Address - Phone:435-723-8841
Practice Address - Fax:435-734-9567
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JER KEN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4884504-17031835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========006Medicaid
UT4246060001Medicare NSC