Provider Demographics
NPI:1790379915
Name:GOUDY, JACOB LUIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LUIS
Last Name:GOUDY
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 1:120 N VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:FRUIT HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2178
Mailing Address - Country:US
Mailing Address - Phone:801-647-3604
Mailing Address - Fax:
Practice Address - Street 1:669 W 900 N
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-2602
Practice Address - Country:US
Practice Address - Phone:888-222-2956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6661108-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist