Basic Information
| Provider Information | |||||||||
| NPI: | 1013527977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOAM | ||||||||
| FirstName: | TREVOR | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1646 N SALEM CIR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852053540 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4460 S HIGHLAND DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841243550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889494864 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2020 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S025500 | AZ | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.