Provider Demographics
NPI:1902400336
Name:DOUBRAVA, EDWARD JOSEPH
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:DOUBRAVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4968 W 13400 S
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6427
Mailing Address - Country:US
Mailing Address - Phone:801-254-6135
Mailing Address - Fax:801-254-7159
Practice Address - Street 1:4968 W 13400 S
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-6427
Practice Address - Country:US
Practice Address - Phone:801-254-6135
Practice Address - Fax:801-254-7159
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10774617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist