Provider Demographics
NPI:1750576070
Name:CHANDRAMOULI, JANE (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:CHANDRAMOULI
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N MEDICAL DR
Mailing Address - Street 2:ROOM A050
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-2073
Mailing Address - Fax:801-585-6688
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:ROOM A050
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2073
Practice Address - Fax:801-585-6688
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT99-374031-1701183500000X
IA18286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist