Provider Demographics
NPI:1891715496
Name:TMJ INC
Entity Type:Organization
Organization Name:TMJ INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-757-7500
Mailing Address - Street 1:8806 S REDWOOD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9337
Mailing Address - Country:US
Mailing Address - Phone:801-747-7500
Mailing Address - Fax:801-747-7504
Practice Address - Street 1:8806 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9337
Practice Address - Country:US
Practice Address - Phone:801-747-7500
Practice Address - Fax:801-747-7504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
UT5810687-17033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2100830OtherPK
UT=========001Medicaid
2100830OtherPK
UT1891715496OtherNPI