Provider Demographics
NPI:1669582045
Name:JOLLEY, TAD HENRY (RPH)
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:HENRY
Last Name:JOLLEY
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 1:8806 REDWOOD RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9337
Mailing Address - Country:US
Mailing Address - Phone:801-747-7500
Mailing Address - Fax:801-747-7504
Practice Address - Street 1:8806 REDWOOD RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9337
Practice Address - Country:US
Practice Address - Phone:801-747-7500
Practice Address - Fax:801-747-7504
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1517711701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist