Evan Dale Theobald, PHARMACIST

Primary specialty

PharmacistTaxonomy code 183500000X

License

143869 Issued in UT

Practice address

1034 North 500 West
Provo, UT 84604

Phone

(801) 357-7051

NPI assigned

Oct 4, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159920000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1952497604",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "668 EAST 770 SOUTH",
            "city": "PAYSON",
            "state": "UT",
            "postal_code": "84651",
            "telephone_number": "801-465-9175"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1034 NORTH 500 WEST",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "84604",
            "telephone_number": "801-357-7051"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "THEOBALD",
        "first_name": "EVAN",
        "middle_name": "DALE",
        "name_prefix": "Mr.",
        "credential": "PHARMACIST",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-10-04",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "UT",
            "license": "143869",
            "primary": true
        },
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "NV",
            "license": "06547",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Pharmacist in Provo, UT
• Providers in Provo, UT by specialty
• Pharmacist in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.