Provider Demographics
NPI:1952497604
Name:THEOBALD, EVAN DALE (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:DALE
Last Name:THEOBALD
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 EAST 770 SOUTH
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651
Mailing Address - Country:US
Mailing Address - Phone:801-465-9175
Mailing Address - Fax:
Practice Address - Street 1:1034 NORTH 500 WEST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-357-7051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT143869183500000X
NV06547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist