Provider Demographics
NPI:1336424498
Name:HALSTEAD, JEREMIAH DANIEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:DANIEL
Last Name:HALSTEAD
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:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84729
Mailing Address - Country:US
Mailing Address - Phone:509-879-2951
Mailing Address - Fax:
Practice Address - Street 1:95 E CENTER ST
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759
Practice Address - Country:US
Practice Address - Phone:435-676-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60226509183500000X
UT12970664-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist