1215144308 NPI number — SAN JUAN PHARMACY MONTICELLO INC.

Table of content: (NPI 1215144308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215144308 NPI number — SAN JUAN PHARMACY MONTICELLO INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN JUAN PHARMACY MONTICELLO 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:
MAIN STREET DRUG & BOUTIQUE
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:
1215144308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 519
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84535-0519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-587-2302
Provider Business Mailing Address Fax Number:
435-587-3441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-587-2302
Provider Business Practice Location Address Fax Number:
435-587-3441
Provider Enumeration Date:
05/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
435-587-2302

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  127088-1703 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 88084876 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 876000616040 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2107592 . This is a "PK" identifier . This identifiers is of the category "OTHER".