Provider Demographics
NPI:1659445187
Name:JOLLEY COMP AND SPECIALTY PHAM
Entity Type:Organization
Organization Name:JOLLEY COMP AND SPECIALTY PHAM
Other - Org Name:JOLLEY'S COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMASIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:801-484-4393
Mailing Address - Street 1:1702 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3424
Mailing Address - Country:US
Mailing Address - Phone:801-484-4393
Mailing Address - Fax:801-484-8677
Practice Address - Street 1:1702 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3424
Practice Address - Country:US
Practice Address - Phone:801-484-4393
Practice Address - Fax:801-484-8677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT33187517033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2107670OtherPK
UT331875-1703OtherUTAH PHARMACY LICENSE #
4602771OtherNCPDP