Provider Demographics
NPI:1730736190
Name:BALLAM, NATHANIEL ROY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:ROY
Last Name:BALLAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 E HIGHWAY 193
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-8533
Mailing Address - Country:US
Mailing Address - Phone:801-771-2994
Mailing Address - Fax:801-771-2996
Practice Address - Street 1:1356 E HIGHWAY 193
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-8533
Practice Address - Country:US
Practice Address - Phone:801-771-2994
Practice Address - Fax:801-771-2996
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021737183500000X
IDP8372183500000X
UT7430082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist