Provider Demographics
NPI:1396055042
Name:MAUGHAN, JESSE LEE (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:LEE
Last Name:MAUGHAN
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 332
Mailing Address - Street 2:
Mailing Address - City:ANNABELLA
Mailing Address - State:UT
Mailing Address - Zip Code:84711-0332
Mailing Address - Country:US
Mailing Address - Phone:435-760-3504
Mailing Address - Fax:
Practice Address - Street 1:1080 S HWY 118
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701
Practice Address - Country:US
Practice Address - Phone:435-896-8489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5887548-1701183500000X
UT5887548-8911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist