Provider Demographics
NPI:1023696481
Name:OGOMORI, ETHAN DREW (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:DREW
Last Name:OGOMORI
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 1:10448 S JORDAN GTWY UNIT 4438
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5427
Mailing Address - Country:US
Mailing Address - Phone:818-648-9976
Mailing Address - Fax:
Practice Address - Street 1:11525 S PARKWAY PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5605
Practice Address - Country:US
Practice Address - Phone:801-316-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10493753-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist