Provider Demographics
NPI:1891791604
Name:SMITH, DONAVAN THALES (RPH)
Entity Type:Individual
Prefix:
First Name:DONAVAN
Middle Name:THALES
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 S 300 E
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754-4429
Mailing Address - Country:US
Mailing Address - Phone:435-527-3972
Mailing Address - Fax:
Practice Address - Street 1:128 SOUTH 300 WEST
Practice Address - Street 2:
Practice Address - City:BICKNELL
Practice Address - State:UT
Practice Address - Zip Code:84715
Practice Address - Country:US
Practice Address - Phone:435-425-3972
Practice Address - Fax:435-425-3923
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT260884-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTX65438Medicare UPIN