1417280678 NPI number — ASSOCIATED FRESH MARKETS INC

Table of content: (NPI 1417280678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417280678 NPI number — ASSOCIATED FRESH MARKETS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATED FRESH MARKETS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FRESH MARKET PHARMACY #2307
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417280678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84126-0908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-978-8225
Provider Business Mailing Address Fax Number:
801-978-8634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3151 KILBY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84098-8309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-645-7945
Provider Business Practice Location Address Fax Number:
435-645-7114
Provider Enumeration Date:
09/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HANSON
Authorized Official First Name:
SHAWNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PHARMACY OPERATIONS
Authorized Official Telephone Number:
801-978-8309

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  7439449-1703 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2121815 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1417280678 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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