Individual
MR. EVAN DALE THEOBALD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHARMACIST
Contact information
Practice address
1034 NORTH 500 WEST, PROVO, UT 84604
(801) 357-7051
Mailing address
668 EAST 770 SOUTH, PAYSON, UT 84651
(801) 465-9175
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
06547
NV
183500000X
Pharmacist
Primary
143869
UT
Other
Enumeration date
10/04/2006
Last updated
07/08/2007
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