Basic Information
| Provider Information | |||||||||
| NPI: | 1265168819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUTCHISON | ||||||||
| FirstName: | ORY | ||||||||
| MiddleName: | BRAD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 517 W 100 N STE 210 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843329826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556061 | ||||||||
| FaxNumber: | 4359949862 | ||||||||
| Practice Location | |||||||||
| Address1: | 152 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MONTPELIER | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832541538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088472108 | ||||||||
| FaxNumber: | 2088472109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2022 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | P8488 | ID | N | Pharmacy Service Providers | Pharmacist | 183500000X | 7792431 | UT | N | Pharmacy Service Providers | Pharmacist | 183500000X | PR55676 | ID | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.