Provider Demographics
NPI:1255351102
Name:CARD, DOUGLAS GRANT (RPH)
Entity type:Individual
Prefix:MISS
First Name:DOUGLAS
Middle Name:GRANT
Last Name:CARD
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 1:121 N 800 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2015
Mailing Address - Country:US
Mailing Address - Phone:801-756-2250
Mailing Address - Fax:
Practice Address - Street 1:5353 N 11000 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003
Practice Address - Country:US
Practice Address - Phone:801-756-8353
Practice Address - Fax:801-756-3525
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT140359-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870309253012Medicaid
UT1003894973Medicare UPIN
UT1168910001Medicare ID - Type Unspecified